Date __________________________

NAME(S)________________________________________________________________

WIT#__________________________________

ADDRESS_________________________________________CITY_____________________

State____ZIP____________________

PHONE _________________________________

CELL PHONE_____________________________

ANNIVERSARY (Mo)______________________ (Yr_____________

LOCAL CHAPTER_______________________________________

E-MAIL ADDRESS _______________________________________

NEW MEMBERS: Please enclose $10.00 Initiation Fee plus

$10.00 annual dues for a total of $20.00.

RENEWALS Enclose $10.00 annual dues for each year of renewal

Check one: _____New Member _____Renewal

Make checks payable to: California State Club of WIT

Send to: Joe Bybee

5809 Burke Way

Bakersfield, CA 93309