PLEASE PRINT ALL INFORMATION ON THE APPLICATION

Level 5 - Platinum Membership $100.00 or more
Level 4 - Gold Membership ---- $50.00 or more
Level 3 - Silver Membership --- $40.00
Level 2 - Bronze Membership - $25.00
Level 1 - Entry Membership ---- $20.00

NAME: _______________________________

ADDRESS: ____________________________

TOWN: ________________ST: ____ ZIP: _______

PHONE: ____________________

EMAIL: _____________________________

MAIL TO: 
UPPER PINE CREEK SPORTSMENS ASSOCIATION
599 BABYLON ROAD
GAINES, PA 16921

Enclosed is: $___________             Circle One
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