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CT VALLEY BUSHWACKER MEMBERSHIP/RENEWAL APPLICATION
Date _________________
Bushwacker Badge Number ______________
First Name _________________________ Last Name __________________________
Alias _____________________________________
SASS # ______________
Address _______________________________________________________________
City ____________________________ State _____ ZIP ________
Home Phone _________________________ Cell Phone ________________________
E-Mail ________________________________________________________________
MEMBERSHIP OPTIONS:
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$90.00 - New Member on waiting list, send no money now (includes new badge)
$20.00 - Annual Renewal
MAKE CHECKS PAYABLE TO: CT VALLEY BUSHWACKERS
Bring your completed application to a Bushwacker event or mail it to:
David G. Heinig
64 Weatherly Trail
Guilford, CT 06437
Revised 1-7-15