MEMBER INFORMATION Type
your information on this web page and then print it out & fax
it to us!
New Member Renewal Member ASA Membership #
Name:
Nickname:
Address:
City:
State:
Zip:
Home #
Work #
Ext #
Mobile #
E-Mail:
DOB:
SSN #
F.E.I.#
Corporate Name:
MEMBERSHIP LEVEL
– (CHECK ONE)
Competition Member..........$50
Competition Family..........$75
Family Memberships ($75) include you plus two (2) other immediate family members (i.e. spouse, or children (under 21). Additional immediate family members under 21 ($20 each).
ADDITIONAL FAMILY
MEMBERS
Name:
Name:
D.O.B.:
D.O.B.:
SSN:
SSN:
Relation:
Relation:
Name:
Add $20.00
Name:
Add $20.00
D.O.B.:
D.O.B.:
SSN:
SSN:
Relation:
Relation:
BOAT INFORMATION
Boat Name (Boat You Will Fish this
Year):
Make:
Length:
Power Manufactured:
# of Motors:
Total Horsepower:
Registration Number:
Trailer Manufactured by:
PAYMENT INFORMATION:
Membership Payment Method:
Total (plus $20 per additional family
member) $
Cash
Check Enclosed Check Number:
Visa ...Master Card ...
American Express (Include all Digits on Credit Card)
|
Card Number
Exp. Date:
Last 3 Digit Number on back of card
(Visa & MC)
Billing Zip:
Print Name on Card:
Signature: X___________________________
Return this form to: ASA, 1653
Whichards Beach Road, Washington, NC 27889, Fax:252-975-4565
Applications are not accepted by phone.