| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Business Phone No.: |
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| Residential Phone No.: |
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| Fax number: |
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| If you ever been a pond officer complete the following |
| Postion Held |
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| Dates Held: |
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| If Yes Where? |
Yes? No?Flight to___________
pond from _______________ pond and has paid for the fiscal year ending__________ |
| New Member Vouched for by Three Ganders |
| 1~ Print Sponsor's Name: |
|
| 1~ Sponsor's Signature: |
|
| 2 ~ Print Sponsor's Name:: |
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| 2 ~ Sponsor's Signature: |
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| 3 ~ Sponsor's Name: |
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| 3 ~ Sponsor's Signature |
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| Please chose only one selection and provide date |
| Please select one box: |
|
| Please insert date |
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| Approval |
| Dated: |
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| Approved:: |
|
