Indiana Audubon Society
Membership Application and Renewal Form

DATE    _____________________

PHONE  _____________________

NAME    _______________________________________________________

ADDRESS ______________________________________________________

CITY    ________________________  COUNTY _________________________ 

STATE ________________________  ZIP ____________________________

E-MAIL   _______________________________________________________

NEW MEMBERSHIP __________   RENEWAL ___________

SEND NEW MEMBERSHIP CARD?    YES [  ]    NO [  ]

Please check the type of membership desired and attach dues:

___ Active . . . . . . . . . .	$30.00 annually
___ Student . . . . . . . . .	$20.00 annually
___ Family. . . . . . . . . .	$35.00 annually
___ Contributing. . . . . . .	$50.00 annually
___ Supportive . . . . . . .	$100.00 annually
___ Life . . . . . . . . . . . . .	$675.00 in one or two payments
___ Library . . . . . . . . . .		$20 (Subscription to the Indiana Audubon Quarterly
by public  library or foreign resident)

Dues include $15.00 subscription to the Indiana Audubon Quarterly and $7.36
subscription to The Cardinal Newsletter.

Make membership checks payable to Indiana Audubon Society, Inc.
and mail to: 
                           Vic Riemenschneider
                           IAS Membership Chair
                           20451 Brick Road
                           South Bend, IN 46637-1418