New Member and Renewal Application
For
renewals, please include your Pedal Talk address label or membership number.
--- PLEASE PRINT ---
Name(s)
___________________________________________________________
Address ___________________________________________________________
City ______________________________ State
_________ Zip ______________
Telephone (_____) ___________________
E-mail
____________________________________________________________
Other club affiliations
_______________________________________________
Emergency name and telephone number
_______________________________________
Your interests: On road __ Off road __ Tandem__ Commuting__ Recumbent__
May we list your phone number in our
directory? Yes__ No__
I (We) will not hold the Granite State
Wheelmen, Inc., its officers or members responsible for any injury or damages
incurred while participating in any club function.
Signature 1 ____________________________
Signature 2 ____________________________
(parent or guardian if under 18)
Membership
rates per household. Please circle selection:
New____ Renewal___
1 year $15____ 3 years $40 ____
New membership includes a choice of:
GSW decal ____ or GSW patch ____
Extra decals or patches, $1.50 each.
___ Decals ___ Patches
Make check payable to and mail to:
Granite State Wheelmen, Inc.
PMB 216
215 South Broadway
Salem, NH 03079-3309