PLEASE PRINT AND COMPLETE 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:  _____________________________________________

CITY: _________________ ST: _____  ZIP: ______

PHONE: ___________________

EMAIL: _____________________________

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

Circle One     
Enclosed is $____________            1 2 3 4 5

Do you want a shirt?  Yes ____ No ____
If yes what size? _________

Do you want items shipped?  Yes ____ No ___
If yes add $10.00 for shipping

Do you want a license plate? Yes ___ No ___
If yes add $10.00 for license plate

5th Level - Platinum includes: Dated Platinum Button, Hat, Shirt - $100.00 or more

4th Level - Gold includes: Dated Gold Button, Hat, Shirt - $50.00 or more

3rd Level - Silver includes: Regular Dated Button, Hat, Shirt - $40.00

2nd Level - Bronze includes: Regular Dated Button, Hat - $25.00

1st Level - Entry includes: Regular Dated Button - $20.00

License Plates cost $10.00 each