Members Name

Address

City State Zip

Home Phone Work Phone

Cell Phone ____________________

** Very Important** If You Would Like To Receive Any Club News

Please Print E-Mail Very Carefully With All Upper & Lower Case Letters Exactly As It Appears On Your E-Mail Address

Example: johndoe@msn.com JohnDoe@msn.com john.doe@msn.com

E-Mail Address

I hereby waive and release The Walleye Searchers of Minnesota their officers, agencies and agents from any and all injuries, death, liability, theft, fire or any loss occurring at any time.

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Signature Date

*********DO NOT WRITE BELOW THIS LINE***********

Amount Paid $ Received By