INTERNATIONAL
                     PRACTICAL SHOOTING CONFEDERATION (ONTARIO)

                          MEMBERSHIP - RENEWAL/APPLICATION

Membership Year: __________                 Renewal:  Yes        No


1,_______________________________ hereby apply for membership in the Ontario Section
of the International Practical Shooting Confederation. I expressly agree to abide by
the principles of Practical Shooting as set out in the IPSC Rule Book. I acknowledge
that if I am accepted for membership, the IPSC identity card that is issued to me is
the property of the Ontario Section of IPSC. I also acknowledge that my membership
in the Ontario section of IPSC may be cancelled or revoked at any time at the sole
discretion of the Board of directors of the Ontario section of IPSC. Should my
membership be cancelled or revoked, I hereby agree to returm the said identity card
to a Director of the Ontario section of IPSC.


Date ________ / ________ / 20______
        mm        dd          yy

First Name __________________________   Last Name ________________________________

Address ______________________________________________________________________

City/Town ________________________________   Province______________________

Postal Code __________________________  Black Badge No. _____________________

Res. Phone (        ) _____________________  Fax. Phone (         )____________________

Bus. Phone (        ) _____________________  Email address ________________________

Home Club ___________________________   Date of Birth ________/________/19______
                                                          mm      dd       yy

Profession _____________________________________________________________________

NOTE: Please provide a fax number, and or email address whenever possible.

Single membership includes SitRep $ 60.00 ($70.00 after January 31)
Household membership (other members in same dwelling)$ 35.00 per member
                                                     $ 45.00 after January 31

I am paying by: (please check one)       Cash       Cheque      Money Order

Total amount enclosed: $ _____________

Please update my Range Officer status and point total, enclosed is a photocopy
of my current Range Officer card:    Yes      No


Signature: _____________________________________


Send to: IPSC Ontario
10 Wilson Avenue,
Lindsay, Ontario, - K9V 5R9
email: ipscont@ptbo.igs.net


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