MEMBERSHIP RENEWAL FORM  
 

Cluck and Quack Poultry Club
20__ MEMBERSHIP

Send renewal with $15.00/family/year to : Al Harris
                                                              Box 41
                                                                           Grosse Isle, MB
                                                                 R0C 1G0
                                                                                  ph: 1-204-467-8654

* Make cheque payable to 'Cluck and Quack Poultry Club'
By becoming a member,
I agree not to use the Membership Directory for any reason
other than personal contact with other members of the Club.

NAME:___________________________________ current member #__________

ADDRESS:________________________________________________________

                  ________________________________________________________

POSTAL CODE:__________________PHONE NUMBER: __________________

EMAIL ADDRESS:__________________________________________________

Preferred Method of Contact for Reminders of Events:
___ Phone ___ Email ___ Text (to_________________________________ )
___ Do not need a Reminder

POULTRY AND OTHER CRITTERS OWNED:

BANTAMS:________________________________________________________
STANDARDS:______________________________________________________
      Pheasants_______________________________________________________
__________________________________________________________________
      Ducks__________________________________________________________
__________________________________________________________________
     Geese__________________________________________________________
__________________________________________________________________
      Other _feathered-_________________________________________________
        _non-feathered-_________________________________________________
     At home Business_________________________________________________
__________________________________________________________________