University of Iowa Alumni Association -- Membership Application

Please print out and complete this form and return it with preferred payment to: Alumni Membership, 100 Levitt Center for University Advancement, Iowa City, IA 52242-1797.
I would like to join the UI Alumni Association.
Name ______________________________________
Street Address ______________________________________
City __________________ State  _______ Zip ___________
E-mail Address ______________________________________
Phone Number _________________________
Second Member ______________________________________ (if applicable)
Membership Level
____ Student Membership -- $20
____ Recent Graduate Membership -- $25 (single or family)
(For those who have graduated within the last five years)
____ Single/Family Membership -- $45
____ Sustaining life $25 - $99. (This level exists for life members who wish to give an annual gift.)
____ Old Capitol Club Platinum Membership -- $750-999 dues [single or family]
Please enter the amount you would like to contribute $______________
____ Old Capitol Club Gold Membership -- $500-749 dues [single or family]
Please enter the amount you would like to contribute $______________
____ Old Capitol Club Silver Membership -- $250-499 dues [single or family]
Please enter the amount you would like to contribute $______________
____ Old Capitol Club Bronze Membership -- $100-249 dues [single or family]
Please enter the amount you would like to contribute $______________
(The Old Capitol Club exists for members wanting to contribute over and above their regular dues. You will receive a receipt for income tax purposes and be recognized in the next UIAA Honor Roll.)
Payment Options
____ Check enclosed (please make payable to the UI Alumni Association)
____ Visa
____ American Express
____ MasterCard
Card Number __________________________________
Expiration Date __________________________________
Signature
 __________________________________