Ameraucana Alliance Membership Form John W Blehm, Secretary/Treasurer John@FowlStuff.com (989)777-1234 Mailing address: Ameraucana Alliance, 4599 Lange Road, Birch Run MI 48415-8137 AmeraucanaAlliance.org Please fill out this form, check the appropriate boxes and mail it along with your check to the above address or use PayPal to pay@AmeraucanaAlliance.org and email the membership form to John@FowlStuff.com. Members receive quarterly Newsletters, may be registered on the Ameraucana Forum, may be listed in the Ameraucana Directory and are eligible for awards and Exhibitor Points for wins at sanctioned meets. Dues are due annually, by January 1st. You may pay dues for up to two years in advance. Dues are not refundable. Children, 17 and under, in your household are included as members under your Individual membership. Due to postage costs only “email” memberships for $10 are available to anyone without a US Zip code. Join in 2015 to be a charter member of The Ameraucana Alliance! □, if you chose to receive Newsletters by email. Annual Individual Membership Dues are $15.00□, if you chose to receive Newsletters by U.S. mail. Check years being paid for: 2015 □, 2016 □, 2017 □ Lifetime Membership Dues with Newsletters by email only are $200/Individual □. Annual Individual Membership Dues are $10.00 MEMBER NAME (same as exhibitor name): CHILDREN (17 and under in household): FARM NAME (if applicable for Breeders Directory listing): ADDRESS: CITY: PHONE: STATE: ZIPCODE: EMAIL: W EBSITE (or Social Media address): Do you want to be registered on the Ameraucana Forum? (please circle one) Yes (email address required if Yes) or No ØØØComplete the section below ONLY if you want to be listed in the Ameraucana Directory××× This is NOT a place to list the varieties of Ameraucana that you own. It is intended to be a reliable source of quality Ameraucana stock that you offer for sale when available. The Ameraucana Directory can be viewed from the Home page of the club’s website. Please Highlight or Circle only the contact information, above, that you want included in your Ameraucana Directory listing. Note: For security reasons some members do not want their physical address listed. I sell eggs and/or birds of the following marked varieties: Bantam Large Fowl ( ) Black ( ) Black ( ) Blue ( ) Blue ( ) Blue Wheaten ( ) Blue Wheaten ( ) Brown Red ( ) Brown Red ( ) Buff ( ) Buff ( ) Silver ( ) Silver ( ) Wheaten ( ) Wheaten ( ) White ( ) White Other Ameraucana (please list): Other Ameraucana (please list): When available I… Sell: Ship? ( ) Hatching Eggs ( ) Hatching Eggs ( ) Day-Old Chicks ( ) Day-Old Chicks ( ) Started Birds ( ) Started Birds ( ) Adult Birds ( ) Adult Birds …and/or I deliver to the shows that I attend (YES) or (NO) Remember your membership must be paid before January 1st to keep it current and have access to the Ameraucana Forum and other member benefits. Please return this form when paying club dues to the Secretary/Treasurer. rev. 6/15