Name: ____________________________________________________________________
                                                           (Please Print Neatly)

Address: ___________________________________________________________________________
                                 Street                                       City                                State                     Zip

County: ____________________________     Telephone: _(_________)_______________________
                                                                                               (Area Code)

DNR District Number: _______  


Membership:  (Please circle one or Highlight accordingly)

             New     Renewal     New Life Member      Current Life Member       


E-Mail Address: ________________________________________

    
 Please check one:      ____ Member – Instructor Number _________________________
                                  ____ Associate Member
                                  ____ DNR Law Enforcement
                                  ____ Apprentice Instructor
                                  ____ Other ____________________________________________

Signature: __________________________________________    Date: ____________________


Make check payable to: Iowa Hunter Education Instructor Association (IHEIA)
New / Renewal Membership - $10.00
New Life Membership - $250.00
New Senior Life Membership - $100.00 (must be 55 years old or older & active 10 years minimum)

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