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Membership Application |  |
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Hampton Roads Weight Pull Club Application for Membership (Please print clearly, or type) Name of Primary, or Single Member: _________________________________________ Second Family Member: _________________________________________________ Family Members: _______________________________________DOB____________ _______________________________________________________DOB____________ _______________________________________________________DOB____________ _______________________________________________________DOB____________ Mailing Address: __________________________________________________________ City_________________________________________State/Prov___________________ Zip__________________________________________Country____________________ Phone #_________________________________________________________________ E-mail Address: _________________________________________________________ Note: Single membership consists of one adult 18 years and older. Family membership consists of any two members of a household 18 years of age or older. Individual .00 Paid by: check__________ Family .00 Paid by: cash __________ Junior .00 Please submit Application with fees (check payable to Arlene D. Cintron, do not mail cash) to: Arlene D. Cintron 1238 Quarter Way Virginia Beach, VA 23464-8510 Signature_______________________________________________Date___________________________ |
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Official Use Only :New _______ Renew_____ Membership # __________ |
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