Name: ________________________________ Spouse:
_______________
EAA/IAC numbers: EAA#________________ IAC#____________________
Adress:________________________________________________________
City: ___________________________State:__________Zip:____________
Telephone: (Hm)________________________(wk
or cell)______________
E-mail
address:_________________________________________________
Checks Payable to:
IAC34
Treasurer $20.00
c/o Caleb Vernick
223 Crestview Rd.
Columbus, Ohio 43202
---------------------------------------------------------------------------------------------------------
Additional Item: