5 RIVERS BASSMASTERS
                                        APPLICATION FOR MEMBERSHIP

Date of Application:_____________
                                                 Applicant Information
Name:_______________________________________
Home Address: _______________________________
                            ________________________________
Home Phone:_______________Work/ Cell Phone:__________________
E Mail Address: ___________________________
Are you a member of FLW ? _________
If yes: Membership ID NO. ________________________
            Date of expiration _____________
Are you, or have you ever been a member of another Bass Club? ______
If yes, identify club name and state_______________________________
Fishing Experience?____________________________________________
Are you a boat owner? _________
If yes:  Model:_________________   Boat Registration # _____________            Length:___________                            Motor HP:_______________
Name of club member sponsoring applicant (if applicable)
                          _____________________________
Point of Contact
Mike Russ, President                                  Dan Brown, Vice President
595-2184                                                        592-0683