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DISTRICT 15 PROMOTIONAL MEMBERSHIP APPLICATION We hereby apply for membership with the District 15 Club Council and enclose the necessary membership fee of $15.00 for one year. We agree to conform to the rules and regulations of the District 15 Club Council and will support its efforts and that of the council’s members in promoting and conducting our organization’s activities. Today’s Date_______________ Track Information: Track Name______________________________________________________________ Physical Address _________________________________________________________ City_________________________________ St_____ Zip_______________ Mailing Address _________________________________________________________ City_________________________________ St_____ Zip_______________ Phone # ______________________ Email ____________________________________ Representative Information: Name ___________________________________________ AMA#_________________ Mailing Address ______________________________________________________ City _____________________ County______________ St ____ Zip ________________ Phone # ___________________ Email______________________________________ Do you want information sent to Track: Yes__ No__ Representative: Yes__ No__ Alternate Rep __________________________________ AMA# __________________ Address ______________________________________ Phone # __________________ Referee _______________________________________ AMA# ___________________ Address _______________________________________ Phone # __________________ Is you Organization incorporated Yes ___ No ___ Date of Incorporation _____________ ______________________________________________________ Signature of Club/Promoter’s Representative Attach the following with this application: $15.00 Charter Fee Mail to: Contact Nick Jones for Address Paid by Check # _________________________ Approved ___________________ Paid by Cash ___________________________ Date ________________________
AMA MEMBERSHIP LIST TYPE OR LEGIBLY PRINT THE FOLLOWING INFORMATION, MAKING SURE ALL REQUESTED INFORMATION IS COMPLETE AND ATTACH TO CHARTER APPLICATION Club Name ______________________________________________ Charter No. ______________________ Address _________________________________________ City ________________ St _____ Zip _________ Be sure you list all members of your club, especially those that are AMA members. Occasionally our office needs access to this information and it must be kept current to maintain accurate records. Throughout the year you should keep us informed of any changes to this list. Your club must consist of at least ten (10) current AMA members including all officers.
Address _____________________________ City _______________________ St ____ Zip _____________ 2. Secretary: ___________________________________ AMA# ____________ Phone __________________ Address _____________________________ City _______________________ St ____ Zip _____________ 3. Referee _____________________________________ AMA# _____________ Phone _________________ Address _____________________________ City ______________________ St _____ Zip ____________ Name Address Zip County AMA# 4._________________________________________________________________________________________________ 5. _________________________________________________________________________________________________ 6. _________________________________________________________________________________________________ 7. _________________________________________________________________________________________________ 8. _________________________________________________________________________________________________ 9. _________________________________________________________________________________________________ 10. ________________________________________________________________________________________________ 11. ________________________________________________________________________________________________ 12. ________________________________________________________________________________________________ 13. ________________________________________________________________________________________________ 14. ________________________________________________________________________________________________ 15. ________________________________________________________________________________________________ 16. ________________________________________________________________________________________________ 17. ________________________________________________________________________________________________ 18. ________________________________________________________________________________________________ 19. ________________________________________________________________________________________________ 20. ________________________________________________________________________________________________
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