IMPERIAL BIRD CLUB

2504 Ave. G NW

Winter Haven, Fl 33880

MEMBERSHIP APPLICATION

2015

Name:___________________________Date________

Address:_________________________

City/State/Zip____________________

Phone:( )_______________________

Cell #:___________________________

E-Mail Address:___________________

Are you a breeder or pet owner?

__________________________

Topics for programs that would be of interest to

you:______________________________________

__________________________________________

Was our club recommended to you, and if so, by whom?

________________

Applicants Signature___________________________

Check correct box:

New Membership_____________

Renewal Membership____________

Check correct box:

Family (2 votes) $20.00______________

Single (1 vote) $15.00_______________

Dues are for one (1) calendar year starting January 1, of the year

paid. Membership must be renewed

annually to retain club privileges.

Come learn and have fun with us!