Pony Express Membership Registration Order Form

Mail this form to: Pony Express Riders of Iowa, Inc.
PO Box 4176  - Des Moines, IA 50333
or contact Carole Bailey at 515-309-9779
____  Life Member
          $30 - voting		 ____  Contributing Member
          $10 - voting
  
____ Family Member
         $5 - 2 votes maximum		 ____ Junior Member
         $.50 - non-voting
  
Name: _________________________________________________

Street Address: __________________________________________

City: ___________________________________________________

State ______ ZIP _______ Phone __________________________

E-mail: ___________________________________________________

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