Name: ______________________________________________________________

Farm Name: __________________________ Social Security Number: ___________

Address: _____________________________________________________________

City: _____________________________ State: ________ Zip Code: ____________

Phone Number: (       ) __________________________________________________

Birthdate: ___________________________

Please Check Type of Membership Desired:
     _____ Individual Member, IAHA & AHAD - $50.00+
     _____ Individual Member, AHAD only - $10.00
     _____ Family Membership (2 Adults), IAHA & AHAD - $95.00*+
     _____ Family Membership, AHAD only - $15.00*
     _____ Youth Membership, IAHA & AHAD (Youth 18 & Under) - $15.00**
     _____ Youth Membership, AHAD only (Youth 18 & Under) - $5.00**

                                                                    AMOUNT ENCLOSED