________________________________________ _______ ______________________________________
Print First Name MI Last Name
_________________________________________ ____________________________________________
Mailing Address: Street or PO Box (Mailing) City, State, Zip Code
__________-______________-_______________ ______________________
Telephone Birth Year Only
__________________________________________________@________________________________
Print Email Address
In the last 5 years, have you been convicted of Game or Fish Law violation, in Pennsylvania? _______ _______
YES NO
If yes, please explain.___________________________________________________________________________________
_____________________________________________________________________________________________________
Do you swear to uphold all Game and Fish Laws? _______ _______
YES NO
Do you understand that as a member, if convicted of a Game or Fish Law violation, your membership may be
revoked? _______ _______
YES NO
I have read and understand the Rifle and Pistol Range Rules and Regulations and agree to abide by them, ______YES ______NO
(Click HERE to read Range Rules and Regulations)
AS A CLUB MEMBER, YOU ARE REQUIRED TO ATTEND AT LEAST ONE MEETING OR HELP WITH AT LEAST ONE CLUB PROJECT PER YEAR, DO YOU AGREE WITH THESE TERMS? _______ _______
YES NO
________________________________________________ __________________________________________
Print Sponsor's Name Sponsor Member's Signature
________________________________________________ ______ /_______/_________
Applicant's Signature Date
**Dues in full must accompany this application**
($16.00 for Jr. members age 12 to 15)
($20.00 for Active Law Enforcements)
Just print this page then fill this application out and mail it to the address at the top of this page.
All information is kept confidential.