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SOUTHERN SHOOTING CENTER LLC
979 Hwy 3185 Lot 199
Thibodaux, LA. 70301
985 - 448-1147
membership@southernshootingcenter.com
Membership #_______________________
Renewal Date _______________________
Membership Application
(PRINT ONLY)
Name _______________________
Address_______________________
CITY ______________ STATE ___________ ZIP _________
DATE OF BIRTH ___________ AGE _____ SPOUSE'S NAME_______________
FAMILY MEMBERS NAME ________________ AGE ____ NAME
______________ AGE _____
NAME ________________ AGE ____ NAME ______________
AGE _____
HOME PHONE ______________WORK _______________CELL
______________
EMPLOYER __________________OCCUPATION _________________
DRIVERS LICENSE INFO: STATE _________ # ________________
E-MAIL ADDRESS __________________________
X" THOSE YOU PREFER ___PISTOL ___RIFLE ____BOW
_____5-MAN SKEET
ARE YOU PRESENTLY A MEMBER OF THE NATIONAL RIFLE ASSOCIATION? ____ IF
YES, WHEN DOES THE MEMBERSHIP EXPIRE? __________
ID# ____________
***If you renew 30 days or more AFTER your expiration date, you will be
required to pay an additional $25.00 re-registration fee. No Exceptions.
I HEREBY CERTIFY THAT I HAVE READ THE SOUTHERN SHOOTING CENTER LLC RULES ON
AND AGREE TO ABIDE BY ALL REGULATIONS IF GRANTED CLUB MEMBERSHIP
I ALSO CERTIFY THAT I AM UNDER NO LEGAL RESTRAINT(S) THAT WOULD PREVENT MY
USING OR POSSESSING FIREARMS FOR SPORTING PURPOSES. I AFFIRM THAT ALL THE
INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST
OF MY KNOWLEDGE.
DATE ____________________ SIGNATURE __________________________________
MAKE CHECK PAYABLE TO: SOUTHERN SHOOTING CENTER
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