Print this form.  Fill it out and Mail it to the address listed below.

___Inividual Membership $40.00   ___Family Membership $45.00  ___Member Information Update Only

Member _____________________________________________Phone #_____________________

Alias ________________________________________________ SASS #_____________________

e-mail _______________________________________________ NRA  #______________________  

Street _______________________________________________ Apt. # or P.O. Box_____________  

City _________________________________________________State ______ ZIP Code _________

Family Member _______________________________________Phone #_____________________  

Alias ________________________________________________ SASS #_____________________  

e-mail _______________________________________________ NRA  #______________________  

Street _______________________________________________ Apt. # or P.O. Box_____________  

City _________________________________________________State ______ ZIP Code _________

Family Member  ______________________________________Phone #_____________________  

Alias ________________________________________________ SASS #_____________________  

e-mail _______________________________________________ NRA  #______________________  

Street _______________________________________________ Apt. # or P.O. Box_____________  

City _________________________________________________State ______ ZIP Code _________

I hereby apply for membership with the Pleasant Valley Renegades.   If accepted as a member, I affirm
that I will abide by the rules, polices and by-laws established by the club, and that I will conduct myself at
all times in a manner that will not bring dishonor to the club, and that I fully support the purposes and
objectives of the club.  

Member Signature  __________________________________________Date___________________  

Family Member or Guardian Signature ___________________________Date___________________  

Family Member or Guardian Signature ___________________________Date___________________  

Make Check payable to:
Liz Gardner.  Write in "Pleasant Valley Renegades" in the memo.  
Mail this form and payment to:
Liz Gardner, 1378 Fowler Ford Rd,  Portland, TN  37148
or bring it to the next club match.  

Range Administration use only:  Liability Waver(s) on File  _______, Membership Approved ________  
Pleasant Valley Renegades  
Membership Application