| Illinois State Twins Association Membership Application Form |
| First Twin Name _________________ __ ____________________ First MI Last |
| Address ______________________ _________________ ___ ________ Street or Rural Route City St Zip Phone Number (____)_______________ |
| Second Twin Name _________________ __ ____________________ First MI Last |
| Address ______________________ _________________ ___ ________ Street or Rural Route City St Zip Phone Number (____)_______________ |
| If under 21 please include parents names. Name _________________ __ ____________________ First MI Last Name _________________ __ ____________________ First MI Last |
| Dues (check appropriate) ___ Twins 12 & under @ $5.00 = $__________ Age ____ ___ Twins 13 & older @ $7.00 = $__________ Age ____ |
| Note. If triplets or other multiples add additional names & information at bottom. |
| Send to: Michelle & Nichelle Bricker, 711 West Jackson, Sullivan, IL. 61951 |