Member Name:

Member Index

Club Rep Name:

Club:

This form is due

Indexes as of 10/25/2010

by 11/15/2010

Mail to: Robbie Puszcz ▪ 2 Glen Abbey Dr. ▪ E. Amherst, NY 14051

Proposed members must have an index of 16.4 and be 16 years old by 5/1/2011. Incomplete forms will not be considered.

Please PRINT. If the information is not clear the proposed member will not be processed.

Proposed Member:

Email:

Address:

Phone:                                              Index:

Proposed Member:

Email:                           

Address:

Phone:                                            Index:

Proposed Member:

Email:

Address:

Phone:                                            Index:

Member Name:

Member Index