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DANSVILLE
FISH & GAME 
PROTECTIVE ASSOCIATION,
INC.
P.O. Box 406,
Dansville, N.Y. 14437-0406
2009 MEMBERSHIP APPLICATION
I do hereby submit my
application for membership or renewal in the DANSVILLE FISH & GAME CLUB
Membership for January 1st – December 31st
PLEASE COMPLETE ALL
SECTIONS
ARE YOU A:
New Member* ( ) ($30 Membership)
Send Membership Application & Fee To:
Renewal: (
) ($30 Membership) Dansville Fish &
Game
Jr. Member (
) ($ 5 Membership) P.O. Box 406
Dansville, NY 14437-0406
NAME:
__________________________________________________________________________________
ADDRESS:
______________________________________________________________________________
CITY, STATE, ZIP +4:
______________________________________________________________________________
PHONE: (______)______-_________ BIRTH DATE:
______/_______/______ AGE: _______(IF UNDER 21)
E-MAIL ADDRESS
(optional):________________________________________________________________
PLEASE NOTIFY US OF ANY ADDRESS CHANGES DURING THE
YEAR
INTERESTS:
Archery ( ) Fishing
( ) Raffles ( )
Bartending ( ) House & Grounds (
) Rifle Range ( )
Blackpowder
( ) Pheasant (
) Skeet/Trap ( )
Cooking ( )
Pistol ( )
Sporting Clays ( )
*Note: New Membership is conditional until approved by Screening
Committee, followed by 1 year’s probation
____________________________________________________________________________
Date Paid: _____/_____/_____
Application Accepted: _____/_____/_____
Screening Committee
Signatures:
Check #:
________________ (1)
_______________________________________________________
Amount: ________________ (2)
_______________________________________________________
Rec'd by: ________________ (3)
_______________________________________________________
Card issued: _____/_____/_____ (4)
_______________________________________________________
Pin: _____/_____/_____ (5)
_______________________________________________________
Sponsor: ________________ Application
Denied ( )
Reason Denied: _______________________________________
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