The Moniteau Creek River Raiders
	2011 Membership Application
	
	Name: ___________________________________________________________
	
	Alias: _______________________________________SASS#:_______________
	
	Address: __________________________________________________________
	
	_________________________________________________________________
	
	Email Address: _____________________________________________________
	
	Phone Numbers:  	Home: _______________________
	
	Work:  _____________________ Cell:  ________________________
	
	Membership Dues:  
	_____Single Membership $25
	_____Family Membership $40  
	_____Enhanced Membership $50 (additional range access)
	
	Please provide the following information for family members when 
	purchasing a family membership:
	
	Name: ___________________________________________________________
	
	Alias: ________________________________________SASS#:______________
	
	Address: __________________________________________________________
	
	_________________________________________________________________
	
	Email Address: _____________________________________________________
	
	Phone Numbers:  	Home: _______________________
	
	Work:  _____________________ Cell:  ________________________
	
	Please make checks payable to MCRR and mail to:
	
	Chuck Wilson
	1715 W Worley St. Suite B
	Columbia, MO 65203