Name ___________________________________________________ Tel. # ( )_________________________________
Permanent Address: Street _____________________________________________________________________________________
City ____________________________________________________________ Zip _____________________
E-mail address _________________________________ Club Affiliation ________________________ Or Independent Member ___
Please check type of application and your division of participation. New ______ Renewal ______
Men 40' _______ , Men 30' (must be 70)________ , Women ________ , NHPA # _______________
Junior Boy _______ , Junior Girl _________ (a junior cannot be greater than age 18 during the entire year).
Junior Boy 20’_______ , Junior Girl 20’ _________ (until end of year following 9th birthday).
* * If you checked Men 30’, or Junior Boy or Girl, please include your Date Of Birth: __________________________
___________________________ APPLICATION DUES & ORDER FORM TOTALS __________________________________________
* ADD $ 5.00 ______ To enter NYSHPA 50/50 DRAWING on labor day Junior State and National Dues $0.00 __________
2011 Adult State and National Dues $27.00 __________
Make check payable to:
NYSHPA or N.Y.S.
Shoulder Patch 2.50 ___________
New
York State Horseshoe Pitchers Association . N.Y.S.
Patch Logo (regular) Decal 2.50 ___________
Please return to: Robert Klock, NYSHPA Sec/Treas. N.Y.S. Patch Logo (inside window) Decal 3.00 ___________
PO Box 478 N.Y.S. Pin 4.00 _________
Spencer, New York 14883
tel. (607) - 589-4122
Email: tictoklock@frontier.com TOTAL Dollar AMOUNT ________________
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