IPTAY Collegiate Club New Membership & Renewal

(found on back of membership card, under the barcode). Student Name ... Please Check Preferred Payment: ... ______ Credit Card ... ______ American Express.
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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