IEAD -I:"@ - Valley Range P- TR- 53f Membership lnformation Address: 1690 Paris St. Aurora Home Phone: Work Phone: ( 858 ) 449_7348 Mobile Phone: Alternate Phone: E-mail Address: Gender: Male Spouse's Name: 12113/87 Y;lJir single /\ iemate _ Birth Date: NRA Member Yes _ No X How did you hear about the Range? _FAST _Gun Show _sportsmen,s Expo _Friend/Farity X On,,n. E I understand th-at r must be 21 years or order to be a member of Lead vafley Range. r understand that no membership will be established with anyone less than Zt y""is oi.g.. Over 21 years of age yes: X No, Are you a US Citizen? yes: X No: Are you prohiblted by state or federar raw fromlossessing firearms or ammunition? Have you ever been convicted of any domestic violence offense? Are there felony criminat charges or domestic violence offenses currenfly pending against you? Are you an unlawful user of or addicted to a controlled substance? Yesl Yes: Yes; Yes: No, X No, -F i I - No: No: x X Holmes 92129 Address: San City Primary Phone: _- Allernate Phone: a I Relationship: Mother Certification I certify that' to the best of mv knowledge and belief, all of the lntormation on this application is true, conect, complete, and il:iilj;:',:il'I *:,1l::'::1i::111"^j::,* t':*vi":l]t;i"ir"" ""ii,'rJ"ppri*tion mav be srounds ror revokins membership and forfeitins any money paid by me. r undersianJil"i;;;i;;i#il;i;il!;;ffi,r";iilii":,: Signature: J6"wu tt'olruw Date: 6125112

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IEAD-I:"@- Valley Range

P- TR- 53fMembership lnformation

Address: 1690 Paris St.

Aurora

Home Phone:Work Phone:

( 858 ) 449_7348 Mobile Phone:Alternate Phone:

E-mail Address:

Gender: MaleSpouse's Name:

12113/87 Y;lJir single/\ iemate _ Birth Date: NRAMember Yes _

No X

How did you hear about the Range? _FAST

_Gun Show _sportsmen,s Expo

_Friend/Farity X On,,n. E

I understand th-at r must be 21 years or order to be a member of Lead vafley Range. r understand that nomembership will be established with anyone less than Zt y""is oi.g..Over 21 years of age yes: X No,Are you a US Citizen? yes: X No:Are you prohiblted by state or federar raw fromlossessing firearms or ammunition?Have you ever been convicted of any domestic violence offense?Are there felony criminat charges or domestic violence offenses currenfly pending against you?Are you an unlawful user of or addicted to a controlled substance?

YeslYes:Yes;Yes:

No, XNo, -F

i

I - No:No:

xX

Holmes

92129

Address:

SanCity

Primary Phone: _- Allernate Phone: a I

Relationship: Mother

CertificationI certify that' to the best of mv knowledge and belief, all of the lntormation on this application is true, conect, complete, andil:iilj;:',:il'I *:,1l::'::1i::111"^j::,* t':*vi":l]t;i"ir""

""ii,'rJ"ppri*tion mav be srounds ror revokinsmembership and forfeitins any money paid by me. r undersianJil"i;;;i;;i#il;i;il!;;ffi,r";iilii":,:

Signature: J6"wu tt'olruw Date: 6125112