MayJune_2012

Clowns of America International
Application and Renewal form
Name: First Middle Initial Last
Street:
City:
State: Zip: Country:
Phone (required):
E-mail:
Date of Birth (required): Age: Male/Female
Clown Name:
Alley Affiliation:
Your COAI Number(if renewing):
Referring Sponsor (if any): Sponsor’s COAI Number:
Gift A Membership
Please gift a membership to the person on this form.
I wish to remain anonymous.
I wish for you to identify me to the recipient.
I wish to write a note: ___________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Please give us your name and phone number so that we can
contact you if necessary. If you wish to remain anonymous
check the box above and we will not reveal your identity.
___________________________________________________
Name Phone #
Annual Membership Dues Rates
NEW U.S.: $40 Active Renewal: $35
NEW International (U.S. funds): $45 Family Renewal (U.S. & Intl.): $17
NEW Senior (65 +): $30 International Renewal (U.S. funds): $40
NEW Senior Intl. (65 +, U.S. funds): $35 Senior Renewal (65 +): $25
NEW Junior Joey (age 8-15): $30 Senior Intl. Renewal (65 +, U.S. funds): $30
LIFETIME Membership: $500 Junior Joey Renewal (age 8-15): $25
• Seniors and Junior Joeys must provide proof of age with application (copy of Birth Certificate, License, etc.)
• Seniors must be age 65 or older within the enrollment or renewal year. Junior Joeys must be age 8 to 15 in the
enrollment year.
• Children age 8 to 15 can choose to join as Family or Junior Joey. Family members can be any age.
• Full members and Junior Joeys receive The New Calliope. Family members do not receive The New Calliope.
Check No. __________
Visa
MasterCard
Discover
Payment Method
Credit Card # __________________________________________________________________
Expiration Date: _______________________ CC Verification Code (3 digits) ______________
Signature
Send Form To:
Clowns of America Intl. Inc. • P.O. Box 1171 • Englewood FL 34295-1171 USA
Phone: 877-816-6941 • 941-474-4351 • Fax: 941-474-8317 • Web site: www.coai.org
All memberships to COAI are on an annual basis.
May/June 2012 Page 49