University of Iowa Alumni Association -- Membership Renewal Please print out, complete this form, and return it with payment to: Alumni Membership, 100 Levitt Center for University Advancement, Iowa City, IA 52242-1797.

I would like to renew my membership in 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 __________________________________

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