MEMBERSHIP APPLICATION

Application fees are as follows: .

65+ $70.00 plus $100.00 a one time initiation fee

under 65 $85.00 plus $100.00 a one time initiation fee

FAIRFIELD FISH AND GAME ASSOCIATION MEMBERSHIP APPLICATION

DATE: _______________________ DOB: ___________________

NAME: ___________________________________________

ARE YOU A VETERAN ______________________________

STATE ID/ DRIVER LICENSE #: _________________________

EMAIL ADDRESS: _________________________________________________________

DO YOU HAVE ANY IMMEDIATE FAMILY MEMBERS THAT ARE CURRENTLY MEMBER(S)? ("Immediate family" - Means a spouse or significant other ("significant other" as used in this definition means one who stands in place of a spouse and who resides with the employee), parents, children, grandparents, siblings, grandchildren, brother- in-law, sister-in-law, daughterin-law, son-in-law, mother-in-law, father-in-law, step-parents, step-children, step-siblings, or a legal guardian or another person who stands in the place of a parent (in loco parentis).

(NAME/RELATIONSHIP) ____________________ ________________________

(NAME/RELATIONSHIP) ____________________ ________________________

(NAME/RELATIONSHIP) ____________________ ________________________

CURRENT STREET ADDRESS: ____________________________________________

CITY: _________________________________ STATE: ________ ZIPCODE: __________

PHONE#: __________________________________

1. LIST THE NAME OF YOUR SPOUSE AND/OR CHILDREN UNDER THE AGE OF (18) EIGHTEEN LIVING IN THE HOUSEHOLD. PLEASE LIST THE AGE OF ALL CHILDREN.

______________________________________________ AGE _______

______________________________________________ AGE _______

______________________________________________ AGE _______

______________________________________________ AGE _______

1. STATE YOUR OCCUPATION OR PLACE OF EMPLOYMENT

_________________________________________________________________

3. WHAT INTERESTS DO YOU HAVE THAT MIGHT BE SERVED BY MEMBERSHIP IN THIS ORGANIZATION:

4. WOULD YOU BE ABLE TO ATTEND AND PARTICIPATE IN THE REGULAR MONTHLY MEETINGS HELD ON THE FIRST MONDAY OF EACH MONTH? YES NO

5. THE CLUB EXPECTS AT LEAST 5 HOURS OF SERVICE EACH YEAR BY EACH MEMBER. IF YOU ATTEND 5 GENERAL MEETINGS YOUR HOURS WILL BE WAIVED. THIS SERVICE CONSISTS OF BUT IS NOT LIMITED TO: CLEANING DEBRIS, PAINTING, CARPENTRY WORK, HELP AT TURKEY SHOOTS OR OTHER EVENTS. YOU HOURS WILL BE RECORDED TO CARETAKER USING A WORKSHEET. (If you work your 5 hours no money is owed to the Fairfield Fish and Game. If you DO NOT work your 5 hours the time will be prorated, Example: if you work 3 hours you will owe Fairfield Fish and Game $30 this equals out to $15 per hour If your spouse/significant other works 5 hours for you their 5 hours will go toward spouse/significant card caring member’s hours. Exempt from 5 hours of work are seniors, out of state residents and handicapped with capabilities.)

DO YOU AGREE WITH THE ABOVE? YES NO

IF NOT STATE REASON BELOW:

_________________________________________________________________

6. LIST ANY FELONY CONVICTION OF YOURSELF OF ANYONE LISTED ON THIS APPLICATION. WITH YOUR ACKOWLEDGEMENT OF THIS, IT WILL ALLOW US TO PROFORM AT OUR DISCRETION A BACKGROUND CHECK OF ALL PERSONS LISTED ABOVE.

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I GIVE MY PLEDGE AS AN AMERICAN TO SAVE, CONSERVE AND TO FAITHFULLY DEFEND FROM THE WASTE NATURAL RESOURCES OF MY COUNTRY, IT'S SOIL, IT'S MINERALS, IT'S FORESTS, AND IT'S WILDLIFE

SIGNATURE _____________________________________________

****SUBJECT TO REVIEW BY BOARD OF DIRECTORS****

DIRECTOR SIGNATURE ____________________________________________

SPONSOR SIGNATURE ____________________________________________

SPONSOR SIGNATURE ____________________________________________

SPONSOR SIGNATURE ____________________________________________