Colusa County Aeromodelers

Membership Application

Date:___________

Last Name:_____________________    First Name:_____________________

Mailing Address:

Street or P.O. Box:________________________________________________

City:__________________                    Zip:_________________

Phone# (primary):__________________ (secondary):_____________________

Residence Address (optional) Street:___________________________________

City:__________________

Current AMA #_________________      Expires:___________________

Dues For 2003

Adult Member    $80.00                            List Family Members

Family               $85.00                            ________________________

Junior                $15.00                            ________________________

Key Charge        $1.00                             ________________________

Key Deposit       $6.00                             ________________________

        Total $___________

Membership Chairman:__________________________________________