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MEMBERSHIP
FORM
Name:___________________________________
DATE________________
Address:_________________________________________________________
City:_______________________
State:___________ Zip:_________________
Home Phone:_________________________
ApHC Number:______________
Email:___________________________________________________________
Additional Family Members:
Spouse’s
Name:_______________________________ ApHC #_____________
Childs Name:
________________________________ApHC #_____________
Childs Name:
_______________________________ApHC #______________
Childs Name:
_______________________________ApHC #______________
Childs Name:
_______________________________ApHC #______________
Family Membership (include children 18 and
Under) $25.00
Individual
Membership
$15.00
Youth Membership (18 and
under) $10.00
Suggestions:_______________________________________________________
_________________________________________________________________
Would you like to be more
active in your club? _______Yes ________No
If so, in what capacity?
Serving on a committee______________________
Assisting at our shows
____________________
Other
__________________________________
Return this completed form with your
check made payable to Free State APHC to:
Sharon Insley
4210 Darnall Rd
Baltimore MD 21236
410-256-5118
[email protected]
Free State APHC, Inc, will not be responsible for any checks,
monies or membership forms given to anyone other that the Free State APHC, Inc.
Membership Chairperson.
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