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Name ______________________________________________________________________ Address ____________________________________________________________________ City ________________________________ State _____________ Zip _________________ County ________________________ Birthdate _______ Phone _______________________ E-Mail Address ______________________________________________________________ Occupation _________________________________________________________________ Check One          _______ New Membership          __________ Renewal Check One Category:           ____ One-Year Membership $25 ____ Two-Year Membership $45 ____ Three-Year Membership $65 ____ Junior (Age 15 & Under) Membership $15 ____ Household Membership $15 (No Magazine. One household member must have full NTA           membership, $15 for each additional household member.) ____ Canadian/Foreign Membership $35 (US Funds) Check Payment Type:    ____ Check    ____ Money Order  ____VISA   ____ Discover                                       ____ Master Card    ____ American Express Credit Card Number ______________________________ Expiration _________________ Signature _________________________________________________________________

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