Membership Form

Please print the following form and mail with yearly dues of $12.50 (payable to NA 40+ Club) to:

                                                          Roxie Hutchinson
                                                          2229 Ferguson Rd
                                                          Stanley, NY 14561                                                                         

Date:_________________________________________________

Name:________________________________________________ Birthday: _____/____/______

Spouse/Significant Other__________________________________ Birthday: _____/____/______

Address: ______________________________________________

_____________________________________________________

Phone(___) _______________ E-Mail Address _____________________________

Anniversary:_____/____/______

If a North American 40+ Touring Rider Member has an emergency, and if it is OK for them to contact you, please check the following ares where you can provide help:

A- Unexpected NA 40+ Touring Rider welcome	A_______
B- Pickup truck or trailer available	B_______
C- Will accept phone call	C_______
D- Have tent space	D_______
E- Have sheltered lodging	E_______
F- Have tools available	F_______

The services you have checked will be coded with address in the membership list.