Name

Address

Street

P. O. Box

City / State/ Zip

NRA Member 

Yes No  

NRA Member #

Would you like to receive information by e-mail?

Yes No

If yes please provide your e-mail address  

Would you like to pay by Check?  

Mail check to   ( ADDRESS ) 

Would you like to pay by Credit Card ?

Master Card  Visa   Discover    American Express

Card Number

Name on the Card 

Expiration Date 

Work Phone Number

Home Phone Number

Will you be willing to help with any of the following?

Help organize and work at matches   Work on a Committee  

Help with Junior Programs