Empire Orienteering Club Membership Application

________New Member ________Renewal


Join in: Jan 1-Jun 30 Jul 1-Oct 31 Nov 1-Dec 31

Student* $5 $5 $5
Individual (21+) $15 $22 $15
Family/Couple $20 $30 $20
Membership     Dec 31 of       Dec 31 of the    Dec 31 of the
good until: the same year following year following year
          *Student=college undergraduate or younger
Please print clearly
Name___________________________________________________________

Year Born________ M/F_____

Address________________________________________________________

________________________________________________________

City___________________________State______ZIP__________

Phone: Home______________________Work__________________________

E-Mail (use CAPS) _____________________________________________


If Family/Couple membership, list other members:

_________________________________________Yr Born______M/F______

_________________________________________Yr Born______M/F______

_________________________________________Yr Born______M/F______

_________________________________________Yr Born______M/F______


Is EMPO your primary club? Y/N___

Make checks payable and send to:
Empire Orienteering Club
P.O. Box 51
Clifton Park, NY 12065
rev. 1/2012