Havasu Gold Seekers, Inc.

                                    P. O. Box 3281     Lake Havasu City , AZ 86405-3281

www.havasugoldseekers.com

  Individual or Family Membership Application

 

__________________________________________________________________________________________________

Last Name                                                              First Name                                                   Spouse or Partner Name

 Name(s) of Minor Children _______________age___       ____________age____        _______________age____
________________age____             __________________age_____

Address  ___________________________City _______________State _________________________Zip _________

Day Telephone ____________________  Evening phone_________________ Cell Phone______________________

Mailing Address(same) ________________________________City _____________________State _____ Zip _____

 E-Mail ___________________________________________________________

Yearly Individual or Family Membership Dues are $30.00 for Jan. 1^st thru Dec 31^st

Initiation Fee for Individual or Family Membership is $70.00

Family Members under 18 years are included

Total cost for new Individual or Family Membership is $100.00

$30.00 for each subsequent year which is Jan. 1^st thru Dec. 31^st

The dues are used to send out a monthly newsletter, pay misc. expenses, and pay the fees on all of the

Club Gold Claims.

  Prospecting Vehicle Make ___________________ Year _____ Color ______ Lic ___________________ State ____

Prospecting Vehicle Make ___________________ Year _____ Color ______ Lic ____________________ State ____

Additional   Vehicle Make ___________________ Year _____ Color ______ Lic ____________________ State ____

Additional   Vehicle Make ___________________ Year _____ Color _____ Lic _____________________ State ____

Base Camp RV                    ___________________ Year _____ Color ______ Lic ___________________  State ____

 
Metal Detector None (  ) Make _____________________ Model ___________________

Other Equipment (Example: Gold King dry washer) ____________________________________________

____________________________________________________________________________________________________________________________________________________________________________

 

Member of GPAA Yes (   )  No (   )