Name: _____________________________________  AMA# ______________

Address: _________________________________________________________

City: _________________________ State:_________ Zip: _________________

Home Phone (___) _____-_________ Work (___) _____-_________

Fax: (___) _____-_________ E-Mail Address: ___________________________

Class:   ( ) Basic       ( ) Sportsman       ( ) Advanced        ( ) Unlimited

Chapter Affiliation: _________________________________________________

ALL Memberships are for Calendar Year! Print and fill out form, send with check payable to IMAC. 1998 Dues are $20 US, $25 Foreign. Newsletter is mailed quarterly via first class mail.

Mail application to:

IMAC
Dave Arndt
2905 Forest Lane
Lorain, OH 44053