RANDONNEURS USA
Membership Application (based on Calendar Year)
___ Renewal ___ New Member
Name : _______________________________________ RUSA#________
Address : _____________________________________________________
City : ____________________________ State: ___ ZIP: ________
Country : _____________________________________________________
Phone : ____________________
E-mail : _____________________________________________________
Local Club : (full name)__________________________________________
Birth Date : _____________________ Gender (M/W/D):________________
M=Man, W=Woman, D=Non-Binary / Decline to State
Signed : _______________________________ Date: _______________
See membership join/renew web page for which fields are public.
Membership Types and Terms - Please check one
Individual : ___ One Year $30 ___Two Years $60 ___Three Years $90
Foreign : ___ One Year $40 ___Two Years $80 ___Three Years $120
Household : ___ One Year $50 ___Two Years $100 ___Three Years $150
-------Complete this section for Household Membership only--------
| |
|Name : ________________________________________RUSA#_______|
| |
|E-mail : ____________________________________________________|
| |
|Birth Date : _____________________ Gender (M/W/D):_______________|
| M=Man, W=Woman, D=Non-Binary / Decline to State |
| |
|Signed :________________________________ Date: ______________|
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Memberships are active for the calendar year.
Members agree to abide by the membership policy.
Amount Enclosed: $____________
Make check payable to Randonneurs USA in US dollars.
Send this form and payment to:
Nigel Greene
RUSA Membership Coordinator
8223 Cadwalader Avenue
Elkins Park, PA 19027
