G. C. Sportsmen's club LTD.

Application available at the range

GLEN COVE PBA PISTOL AND RIFLE ASSOCIATION

APPLICATION FOR MEMBERSHIP

DATE OF APPLICATION: _//

NEW MEMBERSHIP RENEWAL MEMBERSHIP

MEMBERSHIP # _

NAME: _____________________________________

DATE OF BIRTH: _//_ SOCIAL SECURITY #: ___-_-

ADDRESS: _____________

_

DRIVER LICENSE #: DRIVER LICENSE STATE:

PHONE NUMBER: ( ) _-_

EMAIL ADDRESS: ___________@_

PISTOL (PLEASE INCLUDE COPY OF VALID PISTOL PERMIT) RIFLE ONLY

PISTOL PERMIT # __________________ EXPIRATION DATE: /_/_____

RANGE OFFICER (PLEASE INCLUDE COPY OF VALID RANGE OFFICER CERTIFICATION)

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