2011 IROCF MEMBERSHIP FORM

Please submit this form along with your check or money order to Ron Songer, 2013 Ridgeway Drive, Denison, IA 51442. Please fill in the blanks below by printing the information clearly.

Name: ________________________________________________________________________

Street Address: _________________________________________________________________

City: ____________________________________ State: _____________ Zip: _______________

Country (if different than USA): ____________________________________________________

Phone #: __________________________ E-mail: _____________________________________

Enclosed is my check or money order made out to IROCF for:

___ Individual membership at $20.00

___ Family membership at $25.00

(“Family” means Mother, Father, and dependent children all living at the same address)

MEMBERSHIP DIRECTORY INFORMATION

___ Check here if you do not want your information printed in a directory

KEWPIESTA KOURIER INFORMATION

___ Please e-mail me my Kewpiesta Kourier

___ Do not send a Kewpiesta Kourier to this member address by e-mail or by postal mail