Carolina Bassers of Harnett County Chapter 4390 Full Member
		Members Initials
I hereby agree that I have read and understand the rules and regulations of this club.
I understand that the club or club members are not liable for any accidents or property loss.
I understand that if I fail to comply with the rules and regulations of the club that I will be either suspended or expelled.

Name: ____________________________	Signature: ____________________________
Address: ____________________________	Date: ____________________________
____________________________	Home Phone: (_____)___________________
____________________________	Work Phone: (_____)___________________
Email Address: _____________________________________	Cell Phone: (_____)___________________

Are you a Boat Owner? Yes/No. (Please circle one) --- If yes, give description below.

Would you like your phone/Cell phone # to be known by other club members? (Yes / No)

(If no, the information collected above will be used to contact members in emergency situations only)

I hereby state that I am an FLW member.

__________________________	______________________	____________________
Signature	Card #	Card Exp. Date

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--== Receipt – Carolina Bassers of Harnett County yearly dues ==--

__$40.00__ ($55.00 after November)	____________________________________
Dues Paid	Signature of Treasurer or Secretary