CPA Membership Enrollment Form

New Member | Renewal | Change of Address
Name ________________________________________
Address ________________________________________
City ___________________ State______ Zip________
E-Mail ________________________________________

 
Select a membership level from the list below:
 
$25 - Basic Level CPA Bumper Sticker
$130 - 125 Level Basic Level + Plaque
$230 - 225 Level 125 level + CPA Embroidered Jacket ( ) black or ( ) camo
$330 - 325 Level 225 Level + special gift    [Jacket ( ) black or ( ) camo]
$1500 - Corporate Sponsor 1 Yr Membership, 2 Meals, Free Advertising & CPA Dri-Duck Jacket in Camo or Black
 
Enter your payment information below:
 
Check or money order enclosed
Charge my: Visa Master Card Discover
Card# _________________________________________
Exp. Date _________________________________________
Day Phone # _________________________________________
Signature _________________________________________

 

Thank you for your contribution.
 

Print this form and mail to:
Conservation Partners of America
Attn: Scott Scheidt
 1120 McLeod Ave - Glencoe, MN 55336
 (320) 864-6368