“SWVRRC”

MEMBERSHIP APPLICATION FORM FOR YEAR 2011

Mail application to: TYPE OF APPLICATION: SWVRRC

C/O Tom Davis , Treasurer
P.O. Box 1157
Athens , WV 24712 Circle Type : * New * Renewal
PRINT Name _______________________________Print email _____________________________
PRINT Address____________________________________________________________________
PRINT Address ____________________________________________________________________
PRINT City__________________________________ State __ __ Zip __ __ __ __ __
Telephone Number ( __ __ __ ) __ __ __ - __ __ __ __
Date Of Birth: mm/dd/yy __ __ /__ __ / __ __ Circle Sex: *Male *Female Age: _ _

CLUB MEMBERSHIP YEAR IS: JANUARY 1 -- DECEMBER 31

NEW or RENEWAL: Students $8.00 Individuals $12.00 Family* $15.00

* FAMILY APPLICANTS --- please list EACH “additional” family member below:

PRINT Name ____________________________ DOB ___ / ___ / ___ Circle M F

PRINT Name_____________________________DOB ___ / ___ / ___ Circle M F
PRINT Name_____________________________DOB ___ / ___ / ___ Circle M F
PRINT Name_____________________________DOB ___ / ___ / ___ Circle M F
PRINT Name_____________________________DOB ___ / ___ / ___ Circle M F

X_______________________________ _________ Amount enclosed $ _ _ . _ _

Signature of Applicant Date ( Please, do not send cash )

MAKE CHECKS PAYABLE TO : “ SWVRRC ’’