Northampton Revolver Club, Incorporated

Please provide the following contact information:

Name
Address
City/Town
Zip
Age
Phone
Employer
LTC/FID No.
Signature
Nominated by
Dues
Accepted
E-mail
20

In consideration of my membership, I hereby release the Northampton Revolver Club, Incorporated and its members from liability and responsibility for any injury which I may suffer while on the premises
owned or controlled by the Club.

I have received a copy of the Rules and Regulations of the Northampton Revolver Club, Incorporated. I have read and understand them, and hereby agree to be bound by their terms. I also understand
that failure to abide by these Rules and Regulations may result in the loss of my membership privileges.

Circle  either New Application or Renewal

Signed _________________________________            Date _________

Range Officer _________________________

Please print and fill out this application, then call Phil Desorsier at  413-539-8121 or the NRC main number 413-586-7821 to make an appointment for membership. You may also attend one of the quarterly meetings. See the main web site page for dates and times.