Name: 

Address: 

City:      State:     

Country:       Postal Code: 

Phone Number:             Fax Number: 

Email address:  

                                                        Year 1                                Year  2                                    Total

Membership Dues ($15/yr)                         _______                             _______                                 _______

Contribution to the AOS Trophy                                                                                                         _______

                                                                                                           TOTAL                                  _______