WTA Membership Application

First Name: _______________________________

Last Name: _______________________________

Address: _______________________________

City: _________________________________

State: __________________________________

Zip Code: _____________________________

Phone Number: ___________________________

E-mail: _______________________________

Please circle appropriate choices below:

Membership : New Renewal

NOTE: Deduct $5.00 for renewals received before April 15th each year.

Family memberships include spouse and all family members

under 18 years of age at the time of application.

Send application for membership and check to:

Ginger Brockman

4437 Brockman Road

Vesper, WI 54489

920-648-8235