"To stand still is to lose, To move is to gain, To change is to grow"  
--- Gene E. Megiveron
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Heartland Polish Rabbit Club
Counter
Online Membership Form
Individual Memberships $5 -
* Family Memberships $10 -
  • Family Members must all live at the same address
  • Youth turns adult on their 19th Birthday
  • Only 2 adults per family membership
Required Fields are shaded!
Primary Name:
DOB
Member 2 Name:
DOB
Member 3 Name:
DOB
Member 4  Name:
DOB
Member 5 Name:
DOB
Member 6 Name:
DOB
Member 7 Name:
DOB
Member 8 Name:
DOB
Mailing Address:
City:
State:
Zip:
Phone Number:
Email Address:
Website Address:
Polish Varieties raised:
Your other Breeds:
Name of your Rabbitry
  CASH/CHK
 IF USING
PAYPAL
*NEWSLETTER/WEBSITE AD
 $5
 $6
1 YEAR INDIVIDUAL MEMBERSHIP
 $5
 $6
1 YEAR FAMILY MEMBERSHIP
 $10
 $12
1 HEARTLAND POLISH SHOW
SANCTION. (1 OPEN & 1 YOUTH)
 $5
 $6
1 HEARTLAND POLISH PATCH
 $8
 $9
2007 POLISH NATIONAL T-SHIRT
WHILE THEY LAST!!!
 $5
 $6
Send payment to:

Bobby George
3654 N. State Rd. 827
Fremont IN 46737-9779

PAYPAL payments sent to georgebc@gte.net, be
sure to notify me that you used paypal!
$10 a year for a
family membership,

$5 for a Individual
membership,

$8 for a patch,

$5 for a
newsletter/website
ad, Include any
extra amount for a
donation if that is
what you may
choose to do.