Frederick IWLA Applciation

Application for Membership

Name:  ___________________________________________     Date:  ____________________________

Address:  ______________________________________     Home #:  _________________________

                ______________________________________     Work #:  __________________________

City:  ________________________________________ State:  _____   Zip:  ____________________

Occcupation:  ______________________ Email Address:  ______________________________________

Dues: 1 Year 1 1/2 Year after 6/1
Regular (National, State, Chapter) _____ $80.00 _____ $120.00
Family _____ $120.00 _____ $180.00
Youth _____ $15.00 _____ $22.50
Student _____ $35.00 _____ $52.50

Sponsor:  __________________________________________________________________________

Please check the committee (s) in which you are interested:

_____ Archery _____ Legislative _____ Nature Area
_____ Gun Ranges _____ Ways and Means _____ Awards
_____ Fishing _____ Planning _____ Save Our Streams
_____ Conservation _____ Program _____ Other (specify)
_____ Public Relations _____ Food _____________________

Signature ____________________________________

Please print and mail this application with a check payable to Frederick Chapter #1, IWLA, to:
Charles Wiles, Jr.
16021 Comus Road
Clarksburg, MD 20871-9121
301 972-7480 (evening)
301 548-0150, ext. 217 (day)