ONTELAUNEE ROD & GUN CLUB, INC.

Application for Membership

Circle One:

Lifetime Member (under 65 Years of Age) $200.00

Lifetime Member (over 65 Years of Age) $130.00

New Member $20.00

Renewal $15.00

Renewal after May 1^st $20.00

New Junior (Under 16 Years of Age) $5.00

Junior Renewal $3.00

Junior Renewal after May 1^st $5.00

Date of Birth (Jr.) ____________________________

Name ______________________________________

Street Address _______________________________

City _________________ State ________ Zip______

(Please print clearly)

Mail To:

Ontelaunee Rod & Gun Club

P.O. Box 45

Germansville PA, 18053-0045