Dues total: $25.00

Paid: _____ Check ______ Money Order ______ Cash (Please DO NOT send cash by mail)

Dues includes State and National: State dues $10.00, National dues $15.00; State dues good from May to May.

DATE:_______________

Name:__________________________________________________________________

ADDRESS: _____________________________________________________________

CITY: ______________________________ STATE: __________ ZIP: _____________

PHONE: ____________________________

FAMILY MEMBERS: ______________________________________________________________________________

OTHER ANTIQUE CLUBS YOU BELONG TO: __________________________________________________________

IH COLLECTOR ITEMS: __________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

COMMENTS: ______________________________________________________________________________________
_________________________________________________________________________________________________

RETURN TO:
Lovelle Pederson
2327 W. Reinbeck RD.
Hudson, IA. 50643