Membership Application

Date________________________________

Last Name_________________________First___________________MI___ DOB_______________

Alias_________________________________________________

Address___________________________________________________________________________

City_________________________________________State_______Zip_______________________

Phone____________________________ Email address_____________________________________

Spouse Name ____________________________ Birthday ________________________

Indicate membership in the following: NRA Y N Life NRA#__________________________

SASS Y N Life SASS #_____________ NYSRPA Y N Life #__________________

NYS Pistol Permit #_________________ County of issue_________________ Date______________

S/A Revolver #1 Make _________________Cal.____Rev. #2 Make ___________________Cal._____

Rifle Make ____________________________ Model ______________________ Cal.____________

Shotgun Make _________________________ Model ______________________ Gauge___________

Annual Dues are $25.00 made payable to: The Bar-20, Inc.

Send completed application and dues to: Rodney St. Clair, BAR-20 Treasurer

                                                                  P. O. Box 192, Madison, NY 13402-0192

Or you may bring it along to your first shoot.

NO need to complete application unless some info has changed from last year.