Membership & Renewal Form

2011-2012 Membership Dues Application/Renewal

Dues are through June 30, 2012 – Paid members receive a discounted conference fee for the 13^th 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: _______________________________________________