Date:            Sponsor Name:

First:       Middle:     Last:

Street:

City:          State:       Zip:

Date of Birth:      NRA Number:

Home Phone:     Cell Phone:   

Work Phone:       E-mail:          

Occupation:         Employer:     

Do you belong to any other gun clubs?   YES:      NO:

If yes, please list.

Are you a NRA instructor?  YES:     NO:

If yes, please list certificates held.

What shooting disciplines interest you the most? Check all that apply.

I do solemnly swear that the information I have provided above is the truth to the best of my

knowledge and if I am voted in as a Member, I will abide by the By-Laws of The Berwyn Rod

and Gun Club, Inc.’s and the rules governing the Range Operations.

Your Signature_____________________________________________ Date_____________