ITALIAN AMERICAN ASSOCIATION OF KENTUCKIANA

IAA Membership Application

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ITALIAN AMERICAN ASSOCIATION
Membership Application Form
January 1, 2004 through December 31, 2004

New Membership DATE joining IAA _________________________
Renewal Membership
Lifetime Membership Recruited by ______________________________


Last Name First Name Middle Initial/Name

Address City State Zip

Home Phone # Occupation

Work Phone # Fax Phone # E-mail Address

Birthplace and Origin of Heritage Birth Date

SPOUSE INFORMATION: (Fill out if spouse is also joining the club at this time.)


Last Name First Name Maiden Name

Work Phone # Fax Phone # E-mail Address

Birthplace and Origin of Heritage Occupation Birth Date

TYPE OF MEMBERSHIP: Adult membership is $12 per calendar year. Youth membership is $1 per calendar year. All membership dues are renewable on January 1 of each year.

ADULT $12 per year for each person over the age of 18
YOUTH $1 per year for each child under the age of 18
LIFETIME $100 one time payment per person

PLEASE LIST THE NAMES AND BIRTHDAYS OF ALL YOUTH MEMBERSHIPS

__________________________________ ______________________________

__________________________________ ______________________________

May we include your membership information
in the IAA directory? 0 Yes 0 No

AMOUNT ENCLOSED: $ ___________

Please return completed form and dues to: Make checks payable to the ITALIAN AMERICAN ASSOCIATION
Mary Perry, Treasurer
4319 Saratoga Woods Drive
Louisville, KY 40299

Revised 6-3-2004

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