International Utilities Revenue Protection Association

                           IURPA - 2012 Annual Membership



Name: 		___________________________________________________________

Title:		____________________________________________________________

Company:	____________________________________________________________

Mailing Address: ___________________________________________________________

City:		__________________________________     State:  _____________

Country:	_____________________________     Zip Code:  _______________

Telephone:	_______________________________  Fax:_______________________

E-Mail:	_____________________________________________________________________

Utility Type: Gas___ Electric___ Water___ Cable___  Vendor___  Other _________
______________________________________________________________________________

Payment Method:	Check Enclosed ____		Credit Card ____

Credit Card Payments Information:

Name as it appears on the card: ______________________________________________

Billing Address:  ___________________________________________________________

City:  _______________________________________  Zip Code:  ___________________


__ VISA   __MC    __ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __  __

Expires:___ / ___


Note:   Credit card payments may be e-mailed.  Please attach this document and
e-mail to:  george.balsamo@uinet.com

Annual dues are $50 (US) per member.  Payments may be made by check or credit
card.  Please send form along with your payment.  Make checks payable to IURPA
and mail to:

George A. Balsamo
C/o IURPA
3 Elaine Drive
Seymour, CT  06483
FAX (860) 665-2210