Type of Membership:

	Senior (NRA Member)($75): ________	Senior (Non NRA Member)($100): ______
	Adult (NRA Member)($125): _______	Adult (Non NRA Member)($150): ______
	Law Enforcement($75):_______	Business (Standard)($500): ______
	Business (Executive)($1,000): ______	Corporate Sponsorship ($5,000.00): _______
	Junior ($25): ______	(note: A parent or guardian must sign for juniors under 18.)

Date: ____________

Full Name: ____________________________________________

Printed or Typed:

________________________________________________________

_________________________________________________________
Name of Organization (Business/Corporate application)

Address: ______________________________________________

City: ____________________________     State: ____        ZIP_________

Phone: ___________________       Fax: ____________________

Email:______________________________________________

NRA Membership Number:_______________

Date of Birth (mm/dd/yy): ____________________

Sponsor Name (must be member of club): _____________________________

I certify that I am a citizen of good repute of the United States of America or lawfully residing within the United States (Green Card). I am not a member of any organization or group having as it’s purpose or one of it’s purposes the overthrow by force and violence of the Government of the United States or any of it’s political subdivisions; that I have never been convicted of a crime of violence; and that, if admitted to membership, I will fulfill the obligations of good sportsmanship and good citizenship.

______________________________________________     Date:__________________
Signature and Date

I verify that I have received a copy of, understand and agree to the rules and bylaws of the club.

____________________________________     Date: _____________
Signature and Date

Mail completed application and check made out as Cleburne County Shooting Club to:

Secretary - CCSC
P. O. Box 1138
Heber Springs, AR  72543