APHCMembershipForm

ARIZONA PAINT HORSE CLUB

2017-2018 Membership Form

Submission Date

Date

New Renewal

Please select the type of membership:

Youth ($20 - 1 year) Youth ($50 - 3 years) Adult ($35 - 1 year) Adult ($80 - 3 years) Husband/Wife ($45 – 1 year) Husband/Wife ($100 – 3 years) Ranch/Business ($45 – 1 year) Ranch/Business ($100 – 3 years)

(Membership Voting: Adult – 1 vote; Husband/Wife – 2 votes; Ranch/Business – 2 votes)

Business Name

Member Name (1) *

First Name Last Name

Member Name (2)

First Name Last Name

Youth Date of Birth

- Month - Day Year

Parent/Guardian

First Name Last Name

Membership Fee

Mailing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Member (1) Phone

Member (1) Email *

Member (2) Phone

Member (2) Email

APHA Membership Number:

Newsletter Preference:

Email Mail Both

APHC Membership Directories include listing your name, address,
phone number and email address for our other members. If you do
NOT wish to have your information published, please check box to right:

Non-Published

SUBMIT ONLINE BELOW, OR PRINT/MAIL COMPLETED FORM AND PAYMENT TO:

Laura Rogers - P.O. Box 604- Laveen, AZ 85339
602-663-3996 – Lauramarie0614@gmail.com

Payment Method *

Credit Card (add 4%) Check or Money Order

Charge my credit card for the following Membership (select one):

Youth - 1 Year $ 20.00

Youth - 3 Years $ 50.00

Adult - 1 Year $ 35.00

Adult - 3 Years $ 80.00

Husband/Wife - 1 Year $ 45.00

Husband/Wife - 3 Years $ 100.00

Ranch/Business - 1 Year $ 45.00

Ranch/Business - 3 Years $ 100.00

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Enter the message as it's shown *