Pomme de Terre Chapter of Muskies, Inc.

Pomme de Terre Chapter Of MI
Post Office Box #5
Hermitage, Mo. 65668

816-678-1623
George Donner
Chapter President
Email

 


 

 

Missouri Lakes With Muskies
        Lake Pomme de Terre, Fellows Lake, Henry Sever, Hazel Creek and Bush CA #35

Membership Form

 

Please Fill Out All Information

Please print this form, fill-in the appropriate spaces, then mail it with a check
or money order payable to: "MUSKIES, INC."
 
Click Here To Download A PDF Form

  Send To:
     Muskies, Inc.                          Phone Number  573-795-0052
Membership Chairman
C/O Tim Dunaway
602 E. Walnut
Shelbina, Mo. 63468
 

 

 

 

Name 

 

 

 

Address

 

 

 

City/State/Zip

 

 

 

Phone


Home                                                    

Cell             

 

 

Date Of Birth

Email Address

 

 

Chapter Affiliation Choice Number Pomme de Terre Chapter (05)

 

 

Check one: ___ New Member ___ Renewal ___ Address Change ___ Gift___

 

 

My Membership #_________________ Expiration Date_______________

 

  Please choose membership type:
Check appropriate box(s)
___ Regular Member 1 yr - $45.00 ___ Two yr - $75.00 ___ Three yr. - $105.00
___ Family -1 magazine 1 yr - $57.50 ___ Two yr. - $100.00 ___ Three yr. - $142.50
___ Junior Member (must be under 20 years of age) - $30.00
___ Regular Active Military Membership (must use APO/Military Installation address) - $40.00
___ Muskie Research Donation $____________
Name of Spouse_____________________________________
Name of Junior Member_______________ Birthday of Jr. Member_____________
Name of Junior Member_______________ Birthday of Jr. Member_____________
Name of Junior Member_______________ Birthday of Jr. Member_____________

Amount Enclosed____________________

 

 
     

Lets Go Muskie Fishing

Lets Go Muskie Fishing

Lets Go Muskie Fishing