(Complete, print, and send this form, along with your $10.00 membership fee, to the address listed below)

Name: Last First

Address:

City:

State: AL AK AR AZ CA CO DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

University of Oregon: Graduate Student Other

Occupation:

Birth Date: Month Day

Telephone: Home Work /Cell

E-Mail:

Mail to: QUACKER BACKER - 588 East 11th Avenue - Eugene, OR 97401