Non-Affiliated Membership Form

BCHA Non-Affiliated Membership Application

I AGREE TO UPHOLD THE PURPOSES OF BACK COUNTRY HORSEMEN OF AMERICA AND DESIRE A NON-AFFILIATED MEMBERSHIP. I UNDERSTAND THIS IS A NON-VOTING POSITION AND I AFFIRM THAT I HAVE NO LOCAL CHAPTERS IN MY STATE.
Membership Type*

Individual $20Family $23
Primary Member Name*

First NameLast Name
Date of Birth
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address if different from Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home Number*
Spouse Name (For Family Membership Only)
Other Family Member Name 1 (For Family Membership Only)
Other Family Member Name 2 (For Family Membership Only)
Other Family Member Name 3 (For Family Membership Only)
We make every effort to blind carbon copy, so your email address is not public info. Emailing is very important as we will email most notices and information if possible. This reduces costs, with more funds available for trails. Please provide an email address if you have one.

ANNUAL MEMBERSHIP DUES ARE $ 20 FOR INDIVIDUAL/$23 FOR FAMILY (please include all your household members) All dues are due by January 1 of each year. Dues are not prorated for portions of a year.
Signature*

Clear
Payment

You will be emailed an invoice for dues once your application has been accepted.
Signing Date*

MonthDayYear
Date
Should be Empty:

BCHA Non-Affiliated Membership Application