IPTAY - ______ Check (Made out to IPTAY) ______ Credit Card...

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IPTAY Collegiate Club New Membership & Renewal IPTAY Number:__________________ I am new to IPTAY:___________ (found on back of membership card, under the barcode) Student Name:______________________________________________________________ Preferred Mailing Address:____________________________________________________ City:______________________ ______ State:______ Zip Code:____________ Clemson E-mail:__________________________ _______$40.00 for one year membership _______$130 for 4 year membership Please Check Preferred Payment:
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Unformatted text preview: ______ Check (Made out to IPTAY) ______ Credit Card ______ Debit Card Name on Credit/Debit Card:______________________________________________ Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date: ____ / ________ Phone number associated with card: ______ - ______ - ________ ______ Visa ______ Mastercard ______ Discover ______ American Express Mail Completed Application and Payment to: IPTAY Scholarship Fund Collegiate Club Membership P.O. Box 1529 Clemson, SC 29633...
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This note was uploaded on 02/19/2010 for the course MTHSC 104 taught by Professor Simms during the Spring '10 term at Clemson.

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