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/F):__________________

   Signed     : _______________________________ Date: _______________

   Randonneurs USA keeps the above information of each member private.

                 Membership Types and Terms - Please check one

   Individual : ___ One Year $25 ___Two Years $50  ___Three Years $75
   Foreign    : ___ One Year $35 ___Two Years $70  ___Three Years $105
   Household  : ___ One Year $40 ___Two Years $80  ___Three Years $120

   -------Complete this section for Household Membership only--------
   |                                                                 |
   |Name       : ________________________________________RUSA#_______|
   |                                                                 |
   |E-mail     : ____________________________________________________|
   |                                                                 |
   |Birth Date : _____________________ Gender (M/F):_________________|
   |                                                                 |
   |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