| Name: _____________________________________ | Date: _______________________ |
| Address: ___________________________________ | Age (if junior member): _________ |
| City, State Zip: _______________________________ | Phone: ______________________ |
| Breeds of Pigeons owned: __________________________________________________ |
| _______________________________________________________________________ |
| Other Club Affiliations: _____________________________________________________ |
| _______________________________________________________________________ |
| E-Mail address: ____________________ Web Page URL: _________________________ |
| Adult = $10 |
Junior = $5 |
Family = $15 |
|