Peace Valley Bass Anglers

Application for Membership (Please Print Clearly)

Name: _______________________________________________________________
                                    (Last)                                             (First)                                     (MI)

Address: ___________________________________________________________


Telephone: (_____)__________________ (_____)___________________________
                                                    (Home)                                                              (Work)

Cell Phone: (___)_______________________________________

E-Mail Address: _____________________________________________

In Case of Emergency, Notify: ______________________________________

Phone: (_____)_________________________________________

Do You Own a Boat?     Yes     No         If yes please provide the following:

Make & Length of Boat: __________________________________________________

Motor Horsepower: __________

Does it have a working Livewell and Killswitch?     Yes     No

Boat Registration Number: ________________________________________________

Boat Insurance Policy Number and Liability Coverage:


How Did You Hear About Us?             ____ Club Member
                                                       ____ Flyer
                                                       ____ Internet
                                                       ____ Other: ______________________________

I understand that if I am accepted as a member into the PVBA I am expected to make every reasonable effort to participate in all club activities.

 Signature: ________________________________ Date: _______________________

Please Print out this form and mail to:         Peace Valley Bass Anglers
                                                               Attn: Membership Application
                                                               121 Beulah Road
                                                               Doylestown, Pa 18901

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