Beehive Rock and Gem Club

          Membership Application       

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Name:________________________________  Spouse:________________________________

Address:_____________________________________________________________________  

City:__________________________ State:________________ Zip Code:_______________        

Phone:______________________________ Cell:____________________________________  

Email:______________________________________________________

Children:  _________________________________        ________________________________

                 _________________________________         ________________________________

                 _________________________________         ________________________________

 

Annual Dues – Payable on the 4th Week of October of each Calendar Year

Single Membership - $15.00

Couple/ Family Membership - $20.00

Junior Membership - $5.00                                                                                             

(Junior members less than 16 years of age must be supervised by an adult relative or designated Club Member)

Club Magnetic  Name Tags – May be ordered for a fee of $7.50 each

Pleas print clearly on the lines below the names required on each tag.

1. _______________________________        4. __________________________________

2. _______________________________         5.__________________________________

3. _______________________________         6.__________________________________

 

________________________________________________       ________________________

 Signature                                                                                               Date

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      Make Payment to:  Beehive Rock and Gem Club

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                                                     Send to:   Beehive Rock and Gem Club

                                                               P.O. Box 1011

                                                               Ogden, UT  84402 

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