Delaware County Field & Stream
713 Chester Creek Rd Brookhaven, PA 19015
2012 INVOICE
Dear Member,
This is just a friendly reminder that your 2011 membership will expire
on December 31st. Please fill in the form and send it in with your
payment along with a SELF ADDRESSED
STAMPED ENVELOPE.
You may pay by credit card, cash or
check made payable to D.C.F. & S. or renew at the club office between the
hours of 10am to 4pm seven days a week.
Name______________________________________________________________________
Address________________________________________________________
Apt #_______
City__________________________________
State___________ Zip___________________
2011
Membership #___________ DOB____________ Age_______ Phone #_____________________
E-Mail Address ____________________________________________________________________
Þ Would you
like club news e-mailed? ¨ Yes ¨ No
ÞPlease check which
membership you would like.
¨ Family -$150.00 (Includes you,
spouse and any children or grandchildren
up to age 17 )
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¨ Senior Range ----$125.00 (age 18-64) ¨ Senior Citizen----$50.00 (age 65 & over)
¨ Junior Range ----$30.00 (up to age 17) ¨ Conservation----$25.00
¨ Discover Name on Card ___________________________________
¨ Visa
card Credit card
# ____________________________________
¨ Master
Card Expiration Date __________________________________
I herewith
transmit my annual membership dues for 2012
.
SIGNATURE___________________________________________________
**IF PAYMENT IS
NOT POSTMARKED BY JANUARY 31ST 2012, YOUR MEMBERSHIP WILL BE HELD
UNTIL A $20.00 LATE FEE PAYMENT IS RECEIVED. **