Name _____________________________________________
Address __________________________________________
City _____________________ ST _____ ZIP __________
Are you a Member of the NRA Yes ____ No _____
If Joining the NRA, Use NRA ID No. T0028, Club Sale No. C004273D
Age ________ Birthday _______________________________
Home Phone ______ _____ _________

Email Address ____________________________________

Membership Classification Please Check
__ NEW
__ Renewal
__ Annual ($15.00)
__ 3 Year ($35.00)
__ 5 Year ($60.00)
__ Junior ($5.00)
__ Junior Club ($10.00)
__ Senior Club ($20.00)
__ Life Membership ($150.00)
__ Senior Life ($75.00 if over 60)
__ Junior Life ($75.00 if under 21)

I am interested in the following activities
__ High Power
__ Small Bore
__ Hunting
__ Collector
__ Muzzleloader
__ Police Combat
__ Bench Rest
__ Pistol
__ Reloading

THIS STATEMENT MUST BE SIGNED

I Certify that I am a citizen of the United States: that I am not a member of any organization which has as any part of its program the attempt to overthrow the government of the United States by force or violence; that I have never been convicted of a crime of violence; and that if admitted to membership I will fulfill the obligation of good sportsmanship and good citizenship.

Signature_________________________________________

Make checks payable to: Utah State Rifle and Pistol Association
Mail Payment and application to
USRPA Memberships
Darlene Benard
110 South 650 East
Bountiful Utah, 84010