Date: ____/____/____
Name:___________________________________________________________
Address:_________________________________________________________
City, State, Zip:___________________________________________________
Phone: Home_____________________Fax/E-mail_______________________
What types of bird(s) do you keep?___________________________________
________________________________________________________________
Which, if  any, of the birds do you breed?______________________________
________________________________________________________________
Which, if any, of the birds do you exhibit?______________________________
_______________________________________________________________
What other Societies or Clubs, if any, do you belong to?__________________
_______________________________________________________________
Where did you hear about our club?__________________________________
_______________________________________________________________
What other hobbies or interests do you have?__________________________
_______________________________________________________________
How long have you owned birds?____________________________________

DO NOT WRITE _________________________________________________