Membership Application/Renewal Form

International Association for Paratuberculosis, Inc.

Name
Address
Business Phone*
Fax*
Email

* Please remember to include the international and national dialling codes in your telephone and fax numbers.

Fee
 Amount due(US$)
2010 Payment
$50.00
2011 Prepayment
$50.00
Total Remittance

Method of Payment:

Check, US$ funds
Money Order, US$ Funds
Visa card
Mastercard
Amex card
Card Number
Expiration Date
Name on Card
Please print this form and send with payment to

Ray Sweeney, IAP Sec-Treas
112 Barnview Road
Kennett Square, PA 19348
USA
Phone: +1-610-925-6132
FAX: +1-610-925-6800

Source: http://www.paratuberculosis.org/member/memform.htm