Name (Last, First)

Street Address                                                                                                          City, State and Zip Code

Home or Emergency Numbers:   (optional)                              Home Phone                              Cell Phone #                              E-Mail address

E-mail Address                                                                                                          AMA Number

 

 

I request membership in BRCA.  I certify that I am a current member of the AMA and have enclosed:

 

$40.00 for a full-year adult field permit

or

$20.00 for a half-year adult field permit (new members who join after 1 Jul 08)

or

$5.00 for a full-year youth field permit (under age 19)

or

$2.50 for a half-year youth field permit (new members under age 19 who join after 1 Jul 08)

 

I agree to abide by the rules and regulations of BRCA (see BellevueRC.com) and the AMA by my signature below:

Signature of Applicant                                                                      Today’s Date

 

Please make your check payable to BRCA and mail it with this application form to:

Secretary/Treasurer: Ed Jelinek,

                               9930 Harney Pkwy. So.
                               Omaha, NE 68124

                               (402) 397-0640

                               E-Mail Ed

 

YOUR FIELD PERMIT WILL BE MAILED TO YOU VIA U.S. MAIL.