Affiliated with the NMLRA and the VMLRA
PO Box 411
Prince George, Virginia 23875-0411
MEMBERSHIP APPLICATION
NAME_____________________________________________________ DOB___________________
ADDRESS________________________________________________ HOME PHONE_________________
CITY, STATE, ZIP_______________________________________ WORK PHONE_________________
EMAIL ADDRESS______________________________________
ARE YOU A MEMBER OF THE NATIONAL RIFLE ASSOCIATION? YES______ NO_______
NRA MEMBERSHIP NUMBER _____________________________ EXPIRATION DATE____________
ARE YOU A MEMBER OF THE NATIONAL MUZZLELOADING RIFLE ASSOCIATION? YES______ NO_____
NMLRA MEMBERSHIP NUMBER __________________________ EXPIRATION DATE____________
ARE YOU A MEMBER OF THE VIRGINIA MUZZLELOADING RIFLE ASSOCIATION? YES______ NO_____
VMLRA MEMBERSHIP NUMBER_______________ EXPIRATION DATE____________
HOW DID YOU HEAR ABOUT THE JAMES RIVER BLACK POWDER CLUB? ___________________________
SPECIAL INTERESTS THAT YOU MIGHT WANT TO SHARE WITH OTHER CLUB MEMBERS ____________
_____________________________________________________________________________________
I the undersigned have read and will comply with the JRBPC
CLUB USE ONLY ANNUAL DUES: By-Laws Article 1, Secions 1-5.
DUES PAID AS OF _____________ INDIVIDUALS $25.00 APPLICANT'S SIGNATURE
FOR A PERIOD OF _____________ FAMILY $30.00 _______________________________________
MEMBERSHIP CARD #_____________ SENIOR (INDIVIDUAL) $12.50 DATE ____________________________
SENIOR (FAMILY) $15.00 SPONSOR ____________________________