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Saturday, February 4, 2012
Name(s)		Birthdate
		Birthdate
Address
City	StateZip
Phone (with area code)
E-mail
Children		Birthdate
		Birthdate
		Birthdate
Would you like your name listed on a public club membership roster?YesNo
Type of membership: NEWRENEWAL

Membership Fees

One Year	INDIVIDUAL (age 12 and up)	at $10/year
	FAMILY	at $13/year
Three (or more) Year(s)	INDIVIDUAL (age 12 and up)	at $ 8/year
	FAMILY	at $10/year	years
		TOTAL $

I CAN HELP WITH
Safety and Education	Newsletter	Art/graphics
Program activities	Tour planning	Web site
INTERESTED IN
Tandem	Pannier riding
ATB-all terrain bicycle	Recumbent

Print this form, write your check to "Tri-County Bicycle Association" and mail to 

TCBA - Membership
P.O. Box 22146
Lansing, MI 48909-2146

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