Granite Staters Membership Application

No person may become a member of the Granite Staters Chapter unless he/she is a member in good standing of
Family Motor Coach Association (FMCA)

This membership is New ____ Renewal ____ For Information only ____

FMCA # ______________________________________ FMCA Expiration Date _____________________________

Pilot's Last Name _______________________________ Pilot's First name _________________________________

Co-Pilot's Last Name ____________________________ Co-Pilot's First Name ______________________________

Mailing Address ________________________________ City ___________________ State ________ Zip ________

Tel # ________________________________________ E_mail __________________________________

I/we have paid my/our dues or have applied for FMCA membership. Enclosed is a check and I/we understand
that it is for dues and entitles me/us to membership in good standing in the Granite Staters Chapter of FMCA
for the period circled below. (no cash please) PLEASE PRINT MATERIAL IN ABOVE SPACES.

Signature __________________________________ Date _____________________

Dues: $15.00 to May 31, 2012

Dues: $65.00 to May 31, 2016

Circle one of the above!

Make check payable to GRANITE STATERS
Print and fill this form, and mail to:
Beverly Wasson - Membership Chm
484 Deerfield Road
Allenstown NH 03275
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