Name     ________________________________________________________
                    Last                                                      First                                                                     Initial

Address ________________________________________________________________
                    Street

            _________________________________________________________________
                    City                                                                                                    State                                           Zip

Phone        ________________________________ _______________________________
                                        Home                                                          Work

Email__________________________________________



Age___________________ Birthdate_____________________________

I certify that:

            I am a U.S. citizen and 18 years old or older (Or a junior sponsored by an adult member)
           I have the ability to complete a High Power Rifle instructional clinic which includes firing 50 round
            I am not prohibited by federal, state, or local law from purchasing or possessing a firearm.

                                    _________________________________________________________        ________________________
                                                                   Signature                                                                                                  Date

Yearly dues:   $30.00
--Free for Juniors 19 and under if adult from family joins
--Additional adults living at same address, $5.00

Paid:    (       ) Cash              (       ) Check   ** Make checks payable to: "Osage Orange Sharpshooters"

Return to:     Michael Thorn,   290 Nice Place Rd., Clever MO 65631