2009 Idaho Association of Extension 4-H Agents

Membership Form

Name________________________________________________________________

Title_______________________________________County/Office________________

Mailing Address________________________________________________________

Town______________________________________Zip Code___________________

Phone__(208)_____________________________Fax_(208)____________________

Email Address_____________________________________________________________

Number of years you have been a member of IAE4-HA, including the 2009 membership year_________

Please list year you received the following IAE4HA Award: ASA ____MSA ____DSA ____

MAKE CHECKS PAYABLE TO IAE4-HA

Checks must be postmarked before December 1, 2008

Check one:

______$87.50 for New National and State Membership

______$125.00 for National and State Membership Renewals (National dues are $65)

______$50.00 for State Membership Only

______$195.00 for New Lifetime Membership (for retired faculty & staff