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IPTAY Collegiate Club New Membership & Renewal
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IPTAY Collegiate Club New Membership & Renewal
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(found on back of membership card, under the barcode). Student Name ... Please Check Preferred Payment: ... ______ Credi
IPTAY Collegiate Club New Membership & Renewal IPTAY Number:__________________ (found on back of membership card, under the barcode)
I am new to IPTAY:___________
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:
______ 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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