
2011-2012 Membership Dues Application/Renewal
Dues are through June 30, 2012 – Paid members receive a discounted conference fee for the 13th Annual Conference hosted by
Michigan State University, March 18-21, 2012
Please check membership type –
o$50 Individual Membership
o$75 Institutional Membership
(Two to four individuals from the same college or university)
o$100 Benefactor Membership
(Five or more individuals from the same college or university)
o$300 Supporting Membership (Vendors)
($200.00 for vendors who are renewing membership from 2010-2011)
If paying by CHECK, please make check payable to USPA and mail dues form and check to:
Univ.Surplus Property Assoc.
Attn: dELL Burnham
Dept. 3314, 1000 E. University Ave.
Laramie, WY 82071
If paying by CREDIT CARD, please mail dues form to address above or fax to:
dELL Burnham at (307) 766-6762
????Questions????: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. or 307-766-2302
School/Company: ______________________________________________________
Street/Mailing Address: __________________________________________________
City/State/Zip: _________________________________________________________
Individual Membership Name: _____________________________________________
Phone#:__________________________ E-mail: ______________________________
Please list additional names of individuals covered under an Institutional
Or Benefactor Membership:
Name: _______________________________________________________________
Phone#:________________________ E-mail: _______________________________
Name: _______________________________________________________________
Phone#:________________________ E-mail: _______________________________
Name: _______________________________________________________________
Phone#:________________________ E-mail: _______________________________
Name: _______________________________________________________________
Phone#:________________________ E-mail: _______________________________
Method of Payment:
o Check (Check No: ___________)o Visa o MasterCard
Credit Card Number: ______________________________________________
Expiration Date: _________/________________
Name of Cardholder: ______________________________________________
Signature of Cardholder: ________________________________E-Mail__________________________________
Credit Card Billing Address:
Street/Mailing Address: _______________________________________
City/State/Zip: _______________________________________________