Mandatory fields are denoted by an asterisk (*). 

1. Select one membership type* 
___New membership 
___ Renewal (You will need your membership ID number.)        Membership ID# if renewal__________________

2. Select one membership level* 

   

      

         
Regular $35 ___
      
      

         
3-Year Family $100
         __
      
   
   

      

         
Senior (62 and over) $20
         ___
      
      

         
Sponsor $100 __
      
   
   

      

         
Full-time Student/Youth (under
         18) $20___
      
      

         
Business $200__
      
   
   

      

         
3-Year Regular
         $90__
      
      

         
Conservator $250 __
      
   
   

      

         
Family $50 __
      
      

         
Life** $1,000__
      
   

Family Life** 	$1,100 __
**There are no further dues for Life or Family Life members**

3. Provide your membership information Title (e.g., 'Mr.', 'Mrs.','Ms.')
First Name:*_____________________Middle Initial:_____Last Name:*_____________________
Street Address:*_______________________________________________________________
City:*__________________________
State:*_________________________
Zip:* _________________ (plus four if applicable--required for U.S. addresses) 
Country:________________________
Area Code:______ Daytime Telephone:________________________
Area Code:______  Home Telephone:_________________________
Preferred E-mail Address:_________________________________
May We Contact You by E-mail?___Yes ___No 
Membership ID Number (for renewals only)*_______________________________

4. Provide your payment information 
Check*____ Make checks payable to Trout Unlimited
Mastercard*___ Visa*___ Credit Card Number:*_______________________________ 
Expiration Date:* (MM/YY) ___ / ___
Name on Card:*________________________________________