2007 ACA Membership Form
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           Please print form on your printer, fill it out completely and send it along 
           with your payment by US mail to:

           Allegheny Cycling Association
           102 West 9th Street 
           Pittsburgh, PA 15215

           ACA memberships are valid on a calendar year basis (January 1-December 31).     
           All ACA memberships expire on December 31.  

          
           Name:      ________________________________________________________________

           Address:   ________________________________________________________________

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           City:      __________________________  State: ____   Zip Code: ____________

           Phone:     _______________________________ 

           Race Age:  ________________________________
           (As of 12/31/2006) 
           								         
           Email:     _________________________________________________________________

           USCF License Number:  ______________________________________________________

           USCF Cat:   Pro__   Cat 1__   Cat 2__   Cat 3__   Cat 4__   Cat 5__   None__

           Team:      _________________________________________________________________

           Other Club Affiliation (PCC, etc.): ________________________________________

           Medical Insurance: _________________________________________________________

           Person to Call in Case of Emergency: _______________________________________

           Phone:     _______________________________ 

           Cell:      _______________________________ 

           Membership:    Individual $20 per year ____         Family $30 per year ____

           Additional Family Members:   _______________________________________________

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           Comments:    _______________________________________________________________

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