Heartland Polish Rabbit Club - Online Membership Application Form

Todays Date JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/20062007200820092010

IF, FAMILY LIST ALL PERSONS BELOW. INCLUDE BIRTHDATE OF ANYONE UNDER 19. Only 2 Adults per Family Membership, kids OVER 19 years must have their own membership. (*They can be one of the two adults!) Members must have same mailing address to be a family membership. Family Memberships get 2 votes at election time, and Individual Memberships get 1. You must be a member for a year prior to running for office. elections are in EVEN numbered years. (please note: after making a selection it must be a highlighted blue before the file recognizes it as a choice, or it goes to the default choice!)   Applicant1 NAME (youth below): DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/MaleFemale Applicant2 NAME (youth below): DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/MaleFemale Youth1 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale Youth2 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale Youth3 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale Youth4 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale Youth5 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale Youth6 NAME: DOB JanFebMarAprMayJunJulAugSepOctNovDec/01020304050607080910111213141516171819202122232425262728293031/201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987MaleFemale

City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code County Country USACANMEXFOREIGN

Address Phone Number () -

Email Address

** The club prefers to use e-mail in conducting newsletters or meeting information. If you don't have email access then please let us know and a hard copy will be mailed to you twice a year.

CHECK HERE IF YOU YOU WOULD LIKE TO INCLUDE $5.00 FOR A 1 YEAR AD ON OUR WEB SITE OF WWW.HEARTLANDPOLISH.COM. NAME, RABBITRY NAME, VARIETIES RAISED, OTHER BREEDS, PHONE, ADDRESS, EMAIL, AND WEBSITE ADDRESS INCLUDED FOR A YEAR! Ads also go in the Newsletter EACH month! RABBITRY NAME    VARIETIES RAISED BlkBluBrkChoBEWREW Other Breeds Raised

(check your renewal dates ... after 30 days delinquent you are a NEW member again) Dues are $5 Individual & $10 family Mem TypeNEWRenewalDues$5$10$15$20$25$30$35$40$45$50Yrs12345WebNewsletter-Ad$0$5$10$15$20$25$30$35$40$45$50Ad yrs012345Patch$0$8$16$24$32$40Coffee Cup$0$10 Donation $0$1$2$3$4$5$6$7$8$9$10$11$12$13$14$15$16$17$18$19$20$21$22$23$24$25Donated forno thanksAnyVariety AwardsSeason AwardsPostageSanctionsMisc     ------------------------------------------------------------------------------------------> TOTAL Member That Referred you is

WE ACCEPT CASH, CHECK OR MONEY ORDER (PLEASE DO NOT MAIL CASH). $20.00 FEE FOR RETURNED CHECKS FOR ANY REASON.  Memberships start on POSTMARKED date!           MAIL TO: BOBBY GEORGE 3654 N. STATE RD. 827 FREMONT IN 46737-9779   HPRC USE: Receipt Number _______ Received ___/___/___ Payment Type _________ Member Expires ___/___/___