Application for Membership
Please Print Clearly
Name: _____________________________________________________________
Name: _____________________________________________________________
Address: Apt. #:______________________________________________________
City: State: Zip:_______________________________________________________
Telephone# Best time to call:_____________________________________________
Age group:__ junior (<18), __ adult (18-45), __ (>45)
# children at home Names & Ages:________________________________________
Children active in (hobbies):______________________________________________
Emergency Contact::___________________________________________________
Occupation: (He): _____________________________________________________
(She):______________________________________________________
List any skills or hobbies which may be useful for club activities:____________________
____________________________________________________________________
Recommended by (member name(s) or other source):____________________________
Please list the name and location of other bird clubs in which you are currently a member:
State any national bird affiliations:__________________________________________
Major interests in bird related activities (list):__________________________________
___________________________________________________________________
Special skills & experience related to exotic birds:______________________________
___________________________________________________________________
I am willing to speak to the club on the following topics:_________________________
My thoughts for building a better bird club are:________________________________
I keep the following types of birds (list):_____________________________________
___________________________________________________________________
My category is (circle all that apply): pet bird owner, hobbyist, breeder, retailer:
Bird business name & address:____________________________________________
Florida Fish & Wildlife License: Yes No (circle one)
My reasons for wanting to join the Pinellas Exotic Bird Club are:___________________
___________________________________________________________________
Membership Categories (check the one(s) you desire)
___ 15.00 Single - Entitles member to 1 vote and 1 newsletter
___ 20.00 Dual - Two adults at same address, entitles members to 1 vote each and
1 newsletter per address.
Comments you wish to make:______________________________________________
____________________________________________________________________
____________________________________________________________________
I have been informed of the responsibilities of being a member of the Pinellas Exotic Bird Club. I have read and understand the rules of behavior of the Pinellas Exotic Bird Club and agree to comply with the club rules. I also understand that I am required to submit any disputes or disagreements to the Problem Resolution Committee. I agree to pay current dues as a condition of membership. Further, I agree to return all materials to the club in a timely manner and to return all club property owed upon resignation or dismissal from the club. I agree to pay an insufficient/returned check handling fee of $20 as required by club policies and law.
Date: ______________________________________________________________
Signature of applicant:__________________________________________________
Witness: _________________________________________________________________
Submitted with this application is cash or a check which covers the nonrefundable fee of $2.00 and dues of $ for a total of $ ________
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