UTA Membership Application          WE STAND TOGETHER
APPLICANT INFORMATION
First Name:		Last Name:		Office Use Only
Mailing Address:
City:		State:		Zip Code:
Home Phone:		Cell Phone:		Shop Phone:
E-mail:		Website:
Business Name:
Membership Type          NEW:                                   RENEWAL:
International Membership		1 vote and member's rights for one year		$50.00  US
Individual Membership		1 vote, member's rights for a year		$50.00
Family Membership		2 votes, member's rights for a year and includes children up to 16		$75.00
Business Membership		1 vote as a business, 1/4 page advertisement in the Artisan and color listing on the UTA web site		$120.00
Regular Lifetime Membership		All member's rights for life and 1 vote		$500.00
Seniors Individual Membership		Age 60 and up, member's rights for 1 year, and 1 vote		$34.00
Seniors Lifetime Membership		Age 60 and up, member's rights for life and 1 vote		$334.00
Family Lifetime Membership		All member's rights for life as a couple with 2 votes		$750.00
Disabled Veterans Membership		1 vote and member's rights for 1 year		$25.00
Disabled Veterans Lifetime Membership		Member's rights for life and 1 vote		$250.00
Active Duty Military Membership		1 vote and member's rights until discharged		NO CHARGE
				TOTAL ENCLOSED $
SIGNATURES
I hereby certify the information provided on this application is accurate.
Signature of applicant:			Date:
Credit Card #			3 digit security code:
Type card:            VISA                                        Master Card                                        American Express                                       Check/Money Order                                        Check #
Card holder signature:			Card Expiration Date:
Please send payment to: UNITED TAXIDERMIST ASSOCIATION Inc. W7246 Perkinstown Avenue Medford, Wisconsin  54451 1-877-534-4UTA (4882)