Membership registration

To join or renew, simply print and fill out the form below and send to:

The Texas Jack Association
Rick Omohundro, Treasurer
PO Box 91
Salt Lick, KY 40371

NAME: _______________________________________________

MEMBERSHIP TYPE:

____ Individual, $25
____ Junior (under 18), $10
____ Senior (65 and above), $20
____ Family, $40

I have enclosed $________for the following membership(s) in the "Texas Jack" Association.

ADDITIONAL NAMES:

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

ADDRESS: ____________________________________________

______________________________________________________

______________________________________________________

E-MAIL:______________________________________

PHONE: (________) ____________________________

___NEW MEMBERSHIP
___RENEW MEMBERSHIP

BIRTHDATE: ______________________

ARE YOU RELATED TO THE OMOHUNDROS? ____

IF SO, HOW? ______________________________________________________