Evansville Retired Teachers Association

Membership Dues: June 1, 2010-May 31, 2011

Local Dues: Member $10.00 (Associate $5.00)  Check# ___________Cash___________Date______________________

Name____________________________________________________________________

                         Last                                           First                                Middle

Address___________________________________________________________________

                       Street                                         City                                  State

Telephone(_____)______________________E-Mail:_________________________________

Check One:  Retired Teacher__________                      Associate Member__________

ERTA Scholarship Fund receives $1.00 of your dues.

I wish to make an individual contribution to the ERTA Scholarship Fund in the amount of $__________

Check #_______________

Make checks payable to: Evansville Retired Teachers Association

Mail to:  Lino Wiseman, ERTA Treasurer

              5950 Knight Drive

              Evansville, IN 47715-3472