Baker Range, Inc.

Membership Application

3220 Jefferson Street

Baker, LA  70714

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Each membership is for 1 year, please fill out the information below for each member (if family membership).  Please print and bring this form and payment to the range for processing.  (Full payment is required)

Name:            _____________________________________

                      (First, Last)

Spouse’s Name:____________________________________

Street Address:_____________________________________

City, State, Zip  ____________________________________

Home Phone #:_____________________________________

Work Phone #:_____________________________________

Occupation:_______________________________________

Member Recommendation:____________________________

In case of emergency, the management should contact:

Name: ___________________________________________

Relationship:_______________________________________

Phone #:__________________________________________

2nd Phone #:_______________________________________

I have read the Baker Range Membership agreement and agree to adhere to them.

_____________________________           _________________

Member’s signature                                             Date