APPLICATION FOR MEMBERSHIP

LICK CREEK HUNTING CLUB

Date____________________ Driver License#______________________

Telephone#____________________________________________

Name ________________________________________________________

(last) (First) (Middle)

Home Address____________________________________________________________

State___________City_______________________Zip_______________________

Employer_______________________________Working Hrs__________________

Business Address________________________________PH#_________________

Physical Defects_____________________________________________________

Referred By_________________________________________________________

E-Mail_____________________________________________________________

LIABILITY RELEASE

                                              I hereby release the Lick Creek Hunting Club from any injury or less than I may sustain in performing my duties or hunting, etc., as a member of this club

Date_________________Signature of Applicant____________________________