From:

Sent:
To:

'

Sublect:
Attachments:

Glenn A. Rotkovich [membership @ leadvalleyrange.com]

Salurday, July 21,2012 2:23 PM
Perry, David
FW: New Membership
Lead Valley Membership Applicalion.pdf

Here is the e-mail and form.

Glenn

From: James Holmes Imailto:dsherlockb@hotmail,com]

Sentr Monday, June 25, 2012 5:00 PM
To: membershio@leadvallevrange.com
Subject: New Membership
Hi folks,
See the attachment for the membership form.

Cheers,

lames

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Valley Range

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Membership lnformation

1690 Paris St.

Address:

Aurora
Home Phone:

858

449_7348

Mobile Phone:

Work Phone:

Alternate Phone:

E-mail Address:

Gender:

Male

/\

iemate

Birth Date:

12113/87

Y;lJir

single

NRA

Member Yes _

No X

Spouse's Name:
How did you hear about the Range?

_FAST _Gun Show _sportsmen,s Expo _Friend/Farity X On,,n.

I understand th-at r must be 21 years or order to be a member

of Lead vafley Range. r understand that no
membership will be established with anyone less than Zt y""is
oi.g..
Over 21 years of

age yes: X

No,

Are you a US Citizen? yes: X No:

Are you prohiblted by state or federar raw fromlossessing firearms
or ammunition?
Have you ever been convicted of any domestic violence
offense?
Are there felony criminat charges or domestic violence
offenses currenfly pending against you?
Are you an unlawful user of or addicted to a controlled substance?

Yesl

No, X

Yes:

No,

Yes;

No:

Yes:

No:

-F

Holmes
Address:

San

92129

City

Primary Phone:

_-

Allernate

Phone: a

Relationship: Mother
Certification
certify that' to the best of mv knowledge and belief, all of
the lntormation on this application is true, conect, complete,
and
mav be srounds ror revokins
membership and forfeitins
*:,1l::'::1i::111"^j::,*
any money paid by me. r
""ii,'rJ"ppri*tion
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undersianJil"i;;;i;;i#il;i;il!;;ffi,r";iilii":,:

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Signature:

J6"wu tt'olruw

Date:

6125112