Application for Membership (Please Print Clearly)
Name: _______________________________________________________________
(Last)
(First)
(MI)
Address: ___________________________________________________________
__________________________________________________________________
Telephone: (_____)__________________ (_____)___________________________
(Home)
(Work)
Cell Phone: (___)_______________________________________
E-Mail Address: _____________________________________________
In Case of Emergency, Notify: ______________________________________
Phone: (_____)_________________________________________
Do You Own a Boat? Yes No If yes please provide the following:
Make & Length of Boat: __________________________________________________
Motor Horsepower: __________
Does it have a working Livewell and Killswitch? Yes No
Boat Registration Number: ________________________________________________
Boat Insurance Policy Number and Liability Coverage:
______________________________________________________________________
How Did You Hear About Us?
____ Club Member
____ Flyer
____ Internet
____ Other: ______________________________
I understand that if I am accepted as a member into the PVBA I am expected to make every reasonable effort to participate in all club activities.
Signature: ________________________________ Date:
_______________________
Please Print out this form and mail
to: Peace Valley Bass Anglers
Attn: Membership Application
904 Nathaniel Trail
Warwick, Pa 18974-6146