___________________________      ___________________________             ______________________

 (Last Name)                                                        (First Name)                                 (Spouse)

 

Address______________________________________________________________________________

 

City __________________________________ State ___________ Zip __________- ___________

 

Day Phone _____________________ Evening Phone _____________________________________

 

Mailing Address [ same ( ) ] __________________________________________________________

 

City ___________________________________State _______ Zip ________- ________

Yearly individual or family membership dues are $30.00 due by Dec31. Family members under 18 are included.  Initiation Fee (new members) is $70.00

 Total cost for new members is $100.00 and $30.00 there after. The dues are used to send out a monthly newsletter, pay misc. expenses, and pay the fees on all of the Club Gold Claims

Type Prospecting Vehicle  Make (YR) _______________________ Color _______ Lic. # (ST)__________

 Additional Vehicle             Make (YR) _______________________  Color _______ Lic. # (ST)__________

Additional Vehicle              Make (YR) _______________________  Color _______ Lic. # (ST)__________

Additional Vehicle               Make (YR) _______________________  Color _______ Lic. # (ST)__________

 

Metal Detector:  None (  )    Make _______________________________Model_____________________

Other Equipment ( Example: Gold King drywash ) _____________________________________________

______________________________________________________________________________________

Member of GPAA Yes [ ]   No [ ] Member of any other Prospecting Clubs: Name ___________________________________

 

I understand as a member of  Havasu Gold Seekers I can participate in the voting on all major policies and officer elections.

I will also be able to attend all meetings and use the Club Gold claims subject to the Club by-laws.

 Signature ______________________________________________Date__________________

 

Bring this application to the next Club meeting or mail this application and your check to :

 Havasu Gold Seekers, Inc. P.O. Box 3281 Lake Havasu City , Az. 86405 – 3281

                                                 Please fill in Hold Harmless agreement and sign on back of this form

 

Club Bookkeeper Only

 

Date received __________ Initial ____ Amount Received $________ Check # _______ Cash________

 

Havasu Gold Seekers App. 4-1-06 ______________________________________________________________________