PtHA of Illinois Membership Form
Instructions to join PtHA of Illinois
PLEASE TYPE INFORMATION ON THIS FORM BEFORE PRINTING,
SIGN AT BOTTOM AND MAIL IT ALONG WITH THE APPROPRIATE MEMBERSHIP FEE
Name
Street
City State
ZIP Code Country
Phone Cell Phone
Email
Permanent Back Number $5.00 each.
Family Membership
(Spouse, Children 18 &Under) $20 		Senior Membership (19 & Older) $15
Junior Membership (Youth Only) $10

Family Members -** List name and date of birth for each person covered in the membership please

Name DOB
Name DOB
Name DOB
Name DOB
A membership card and number will be issued. If you do not receive this card, check with the treasurer.
It will be your responsibility to secure membership, and your number will be recorded.
I/We hereby agree to abide by the rules and regulations of the PtHA of Illinois as outlined in the constitution.

Signature Date

Please mail your completed form and your payment to:
PtHA of IL
c/o Barb Petrovic
20336 Wallingford Lane
Deer Park, Il 60010

Office Use
Memb. #______
Card ______

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