membership form

DSRA USE ONLY	DIAMOND STATE RODEO ASSOCIATION
_________________
MEMBER NUMBER
_________________
DATE RECEIVED
MEMBERSHIP APPLICATION
MAIL TO: P.O. BOX 190441
LITTLE ROCK, AR 72215-6503
TELEPHONE: 501-562-4466
WEB: WWW.DSRA.ORG
YEARLY MEMBERSHIP: $36.00

PLEASE READ CAREFULLY: ALL INFORMATION MUST BE FILLED IN, SIGNED AND DATED FOR MEMBERSHIP APPLICATIONS TO BE VALID AND ACCEPTED. PLEASE PRINT ALL INFORMATION IN INK.

NAME:____________________________________________ ALIAS:_________________________
I GIVE PERMISSION TO USE MY FIRST NAME AND LAST INITIAL IN ALL DSRA PUBLICATIONS?____YES____NO

DOB:________ I AM 21 YEARS OF AGE OR OLDER___YES ___NO

MAILING ADDRESS: STREET:_________________________________CITY:__________________ STATE:____ZIP:________
I WOULD LIKE TO RECEIVE MAIL AT MY MAILING ADDRESS? _____YES ____NO

HOME PHONE: (___) _____-_________ WORK OR CELL: (____) _____-__________
PLEASE INDICATE IF WE MAY REACH YOU AT THE TELEPHONE NUMBER(S) ABOVE? ____YES ____NO

E-MAIL ADDRESS:_____________________________

SPECIAL SKILLS:____LEGAL ____ACCOUNTING _____FINANCIAL____GRAPHIC ART____ COMMUNICATIONS _____SECRETARIAL ____OTHER (PLEASE SPECIFY)______________________________________________________

AREAS OF INTEREST: _____RODEO ______RODEO PARTICIPATION _____COUNTY/WESTERN DANCE(TEACH OR LEARN) ____PUBLIC RELATIONS ____FUND RAISING ___ENTERTAINMENT _____NEWSLETTER____CLUBHOUSE___OTHER (PLEAS SPECIFY)_______________________________________________________________________________________________

FOR AND IN CONSIDERATION OF THE ACCEPTANCE OF THE MEMBERSHIP APPLICATION AND MY BEING A MEMBER OF DSRA. INC. WITH ITS RIGHTS AND PRIVILEGES. THE UNDERSIGNED DOES HEREBY AGREE TO PROTECT AND INDEMNIFY AND HOLD HARMLESS DSRA.INC FROM ANY AND ALL DAMAGE, INJURY, OR DEATH WHICH MIGHT OCCUR TO THE UNDERSIGNED OR THE UNDERSIGNED'S PROPERTY IN PREPERATION FOR, DURING AT, OR FOLLOWING ANY FUNCTION HELD BY OR FOR THE BENEFIT OR DSRA. INC. AND ALSO FROM ANY AND ALL LIABILITY WHAT SO EVER IN REGARD THERETO WHETHER AND CAUSE OF ACTION MAY OCCUR TO YOU, YOUR EXECUTOR, ADMINISTRATOR OR ASSIGNS.

DSRA MEMBERSHIP LIST IS CONFIDENTIAL AND WILL BE USED FOR OFFICIAL DSRA BUSINESS ONLY APPLICANTS SIGNATURE:________________________________________DATE:________________ PLEASE PRINT THIS FORM AND MAIL IN WITH CHECK OR MONEY ORDER OR TURN IN AT NEXT DSRA EVENT WITH CASH, CHECK OR MONEY ORDER



AFTER PRINT CLICK HERE TO RETURN HOME

DSRA USE ONLY

DIAMOND STATE RODEO ASSOCIATION

_________________

MEMBER NUMBER

_________________

DATE RECEIVED

MEMBERSHIP APPLICATION

MAIL TO: P.O. BOX 190441

LITTLE ROCK, AR 72215-6503

TELEPHONE: 501-562-4466

WEB: WWW.DSRA.ORG

YEARLY MEMBERSHIP: $36.00

PLEASE READ CAREFULLY: ALL INFORMATION MUST BE FILLED IN, SIGNED AND DATED FOR MEMBERSHIP APPLICATIONS TO BE VALID AND ACCEPTED. PLEASE PRINT ALL INFORMATION IN INK.

NAME:____________________________________________ ALIAS:_________________________

I GIVE PERMISSION TO USE MY FIRST NAME AND LAST INITIAL IN ALL DSRA PUBLICATIONS?____YES____NO

DOB:________ I AM 21 YEARS OF AGE OR OLDER___YES ___NO

MAILING ADDRESS: STREET:_________________________________CITY:__________________ STATE:____ZIP:________

I WOULD LIKE TO RECEIVE MAIL AT MY MAILING ADDRESS? _____YES ____NO

HOME PHONE: (___) _____-_________ WORK OR CELL: (____) _____-__________

PLEASE INDICATE IF WE MAY REACH YOU AT THE TELEPHONE NUMBER(S) ABOVE? ____YES ____NO

E-MAIL ADDRESS:_____________________________

SPECIAL SKILLS:____LEGAL ____ACCOUNTING _____FINANCIAL____GRAPHIC ART____ COMMUNICATIONS _____SECRETARIAL ____OTHER (PLEASE SPECIFY)______________________________________________________

AREAS OF INTEREST: _____RODEO ______RODEO PARTICIPATION _____COUNTY/WESTERN DANCE(TEACH OR LEARN) ____PUBLIC RELATIONS ____FUND RAISING ___ENTERTAINMENT _____NEWSLETTER____CLUBHOUSE___OTHER (PLEAS SPECIFY)_______________________________________________________________________________________________

FOR AND IN CONSIDERATION OF THE ACCEPTANCE OF THE MEMBERSHIP APPLICATION AND MY BEING A MEMBER OF DSRA. INC. WITH ITS RIGHTS AND PRIVILEGES. THE UNDERSIGNED DOES HEREBY AGREE TO PROTECT AND INDEMNIFY AND HOLD HARMLESS DSRA.INC FROM ANY AND ALL DAMAGE, INJURY, OR DEATH WHICH MIGHT OCCUR TO THE UNDERSIGNED OR THE UNDERSIGNED'S PROPERTY IN PREPERATION FOR, DURING AT, OR FOLLOWING ANY FUNCTION HELD BY OR FOR THE BENEFIT OR DSRA. INC. AND ALSO FROM ANY AND ALL LIABILITY WHAT SO EVER IN REGARD THERETO WHETHER AND CAUSE OF ACTION MAY OCCUR TO YOU, YOUR EXECUTOR, ADMINISTRATOR OR ASSIGNS.

DSRA MEMBERSHIP LIST IS CONFIDENTIAL AND WILL BE USED FOR OFFICIAL DSRA BUSINESS ONLY

APPLICANTS SIGNATURE:________________________________________DATE:________________

PLEASE PRINT THIS FORM AND MAIL IN WITH CHECK OR MONEY ORDER OR TURN IN AT NEXT DSRA EVENT WITH CASH, CHECK OR MONEY ORDER

AFTER PRINT CLICK HERE TO RETURN HOME