Membership Form

Please print this form, fill-in the appropriate spaces, then mail with a check or money order payable to: "Midwest Musky Club."

Send to:
Midwest Musky Club
c/o Eddi Bock
7312 W. 110th Pl.
Worth, IL 60482

Name_____________________________________________________________________________________

Address___________________________________________________________________________________

City/State_________________________________________________ Zip Code _________________________

Phone_____________________________________________________________________________________

E-mail Address______________________________________________________________________________

Occupation_________________________________________________________________________________

Do you own a boat?     YES______     NO__________

Were you sponsored by a current member? If so, who  ______________________________________________

My Membership #_________________ Expiration Date_______________

Check one: ___ New Member ___ Renewal ___ Address Change ___ Gift

Please choose membership type:
Check appropriate box(s)

___ New Member 1 year - $40.00  (includes hat and can cooler)

___ Regular Member 1 year - $30.00  

___ Additional Family Member each 1 year - $10.00 ___ 

___ Senior Member- $15.00 

___ Muskie Research Donation $____________

Name of Spouse_____________________________________

Name of Family Member_______________

Name of Family Member_______________

Name of Family Member_______________

Name of Family Member_______________

Name of Family Member_______________