Form must be mailed (not submitted at meetings) and make checks payable to BANV, 2918 North Rosser St,

Alexandria, VA 22311

2012 Member Information (Please BLOCK PRINT CLEARLY)

Full Name:
Last (Family Name) First (Given Name) M.I. Apartment/Unit # State ZIP Code

Address:
Street Address City

Home Phone: E-mail Address: Did you take the BANV Beginner Course What year?

Alternate Phone: Office

Cell

Yes

No

BANV 2012

Membership & Subscriptions Beekeepers Association of Northern Virginia (make check to BANV and mail to BANV, 2918 North Rosser St., Alexandria, VA 22311) Membership for Feb 1, 2012 Jan 31, 2013: $20.00/yr/Household Includes $10 Virginia State Beekeepers Association membership for July 1, 2012 June 30, 2013. NOTE!!: If State dues paid through another VA club or not a VA resident, deduct $10 and indicate other club here: __________________________ Check Number: Bank: TOTAL $