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