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Membership Application 2012 MOSQUITO CREEK SPORTSMEN'S ASSOCIATION, INC. P.O. Box 218, Frenchville, Pa. 16836 |
Office Use Only |
Member Card# ____________ Member Type 2012 Life |
Issued by: |
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PLEASE PRINT. *MUST INCLUDE DATE OF BIRTH (DOB). APPLICATIONS WITHOUT DOB WILL NOT BE PROCESSED. MAIL-IN APPLICATIONS MUST INCLUDE SELF ADDRESSED, STAMPED ENVELOPE TO RECEIVE MEMBERSHIP CARD. |
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| (Check all that apply)
Application Date __________________ New Member Returning Member (2011 Card#_______________________) Male Female 2011 Memberships (*Valid 1/1/11 - 12/31/11) Senior: 21 & Over - $10.00 Junior: 18-20 years - $5.00 Youth: 0-17 years - $3.00 Life: 60 & over - $150.00 (one time app.) Life: 65 & over - $125.00 (one time app.) |
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| Name: _____________________________________________________ | DOB* _________/_____/___________ | |||||
| First | Middle | Last | Month Day Year (4-Digit) | |||
| Mailing Address
________________________________________________ _____________________________________________________________ |
Current Age ______________________ | |||||
| Phone (_____) ________-_________ | ||||||
| City_________________________________State________Zip__________ | E-mail ___________________________ | |||||