SAPIC MEMBERSHIP APPLICATION
SAPIC is a non-profit organization 501 (c) (3). Contributions are deductible
under sections 170, 2055, 2106 or 2522 of the Internal Revenue Code.

Date: _________________    New Membership: _________    Renewal: __________


Name ________________________________________________________________


Address ______________________________________________________________


City ___________________________ State:  ______ Zip Code (+4) _____________


Telephone: __________________ E-mail: _________________________________

(Please check)

Individual $25: _______ Family $35: _______ Lifetime Individual $200: _______

Business/Organization $40: _______


DONATION or MEMORIAL: $ _________________


List names of honoree(s) if desired: ________________________________________

MAIL TO:

SAPIC c/o Brad Hughes
308 NW Sunset Lane
Grimes, IA 50111