Please note: Due to AMA insurance requirements, all applicants must show a current AMA card
or receipt to renew membership in the club.

PLEASE PRINT

NAME:___________________________________________________________

AMA Number:_____________________________________________________

ADDRESS:________________________________________________________

CITY:____________________________________________STATE:__________

ZIP:_____________
PHONE:__________________________________

Cell PHONE:______________________________

DATE:___________

RAFFLE TICKET #s:______________________________________________

E-MAIL ADDRESS:_________________________________________________

BY SIGNING THIS FORM, I AGREE TO ABIDE BY THE RULES AND REGULATIONS
OF THE JACKSON RADIO CONTROL CLUB, INC. FAILURE TO DO SO
COULD RESULT IN DISMISSAL FROM THE CLUB WITH NO DUES REFUNDED.

SIGNATURE OF APPLICANT:____________________________________________

2010 DUES ARE TO BE SUBMITTED WITH APPLICATION.
AMOUNT:___________

 PLEASE send completed application* with dues attached to:

Mark Harris
3101 Hendee Road

Jackson, Michigan 49201

*Receipt of payment will be sent via e-mail address provided. If you do not have an email address, please include a stamped self-addressed envelope with your application.