Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone *

(###)

###

####

Membership Category *

School District - $500

CESA - $500

Institution of Higher Education - $500

Public Library System - $500

Associate - $350

Individual - $50

Student - $25

Payment Option *

Please check one

Check payable to WiRSA (Mail to: W16381 Rabbit Run Rd Taylor, WI 54659)

Bill my organization (Include purchase order # below)