FLW. #:  ___________________________________  E-mail:  _____________________________


ADDRESS: _________________________________________________________


CITY: _______________________________ STATE: ____________ ZIP: ____________


HOME PHONE: ______________________ WORK PHONE: ___________________


BOATER: ____ NON BOATER: ____ SPOUSE'S NAME: _________________________


BOAT-MAKE: _____________________________________ LENGTH: _____________

HORSEPOWER: _____________________ LIVEWELL? YES / NO

NUMBER OF YEARS BASS FISHING: ___________

IN SIGNING THIS APPLICATION, I HEREBY WAIVE AND RELEASE ALL OTHER CLUB MEMBERS, OFFICERS AND SPONSORS FROM ALL CLAIMS OF LOSS, INJURY AND/OR DAMAGE INCURRED IN CONNECTION WITH MERCER COUNTY BASS OR TOURNAMENTS HELD BY MERCER COUNTY BASS. I FURTHUR UNDERSTAND AND AGREE TO THE RULES AND BY-LAWS OF MERCER COUNTY BASS.


SIGNATURE: _______________________________________________

PLEASE PRINT OUT AND COMPLETE APPLICATION IF INTERESTED. NEW MEMBERS ARE WELCOME AT OUR MEETINGS.