5198 Arlington Avenue # 146 ,  Riverside, CA 92504-26-03                                         

Home                                         INLAND KOI SOCIETY   Membership Application                    

PLEASE PRINT ALL INFORMATION:    ____YES, I (We) would like to join the Inland Koi Society:                                                                                     

Name (s):_________________________________________________________________________________________

Address: ____________________________________________ City: ________________ State:_______ Zip: ______________

Phone:____________________ Fax:___________________ Cell:________________  Email:____________________________

Are you willing to receive the Newsletter by email instead of a mailed copy? _______ Yes  _____ No

Please check items you would like EXCLUDED from the published Membership Directory:

                                       ___Name    ___Address  ___City  __Phone  __Fax   __E-mail  

I/We currently subscribe to KOI USA ______  Yes   _____ No

I (We)  currently have: __ a Pond      __ a Water Garden __     Koi or other Fish   __  Any problems? __ Yes  ___ No   If so, what kind. ______________

How did you hear about our club?    ___ Koi USA  ___Koi Show  ___ Pond Tour ____ Member, who_________________________ 

Koi Dealer, who  ________________________    Other:______________________     Internet _______________    

Have you attended any of our pond tours or auctions? ___Yes  ____No

Name to appear on new member's name badge:         #1_________________________Please select badge style _____Pin type or _____Magnetic
Additional name(s) for additional badge(s) at $7.00 each                  Please select:

#2__________________________________________________     ____Pin     ____Magnetic       @$ 7.00 each        $________    

#3__________________________________________________      ____Pin     ____Magnetic          @$7.00 each     $________

#4__________________________________________________       ____Pin     ____Magnetic         @$7.00 each     $________

New Member Dues ($35.00; if after July 1, prorate to $23.00) . . . . . . . . . .                                                                      $________

 KOI USA subscription (1 year, Member discount). . . . . .  . .  @20.00 . .                                                                      $________                                                              

TOTAL AMOUNT ENCLOSED                                                                                                                                              $________

Signature______________________________ Date______________ Amount paid:                                                      $________
Print and then send completed form and check (made payable to Inland Koi Society to:

 Inland Koi Society-Treasurer, 5198 Arlington Avenue #146,  Riverside, CA 92504 -2603

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