MEMBERSHIP and/or INSURANCE APPLICATION 2010

Team Information

Please conplete the information below.

We acccept online payments using MasterCard or Visa.

STATE:

TEAM NAME:

CONTACT FIRST NAME:

CONTACT LAST NAME:

ADDRESS:

CITY, STATE, ZIP:

HOME PHONE / AREA CODE:

CELL PHONE / AREA CODE:

EMAIL:

AGE DIV:

CLASSIFICATION:

AFA TEAM ROSTER

Please conplete the team roster information below.

(One player per line please.)

FIRST NAME    LAST NAME     BIRTH DATE

ADDITIONAL INSUREDS (Park or City not individuals)

Fill out if needed for Insurance Application only (1st one free, 2nd and up $25.00 each)

1.

2.

3.

4.

NAME                ADDRESS              CITY               ST       ZIP                FAX

81012141618Open

AB

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MEMBERSHIP

INSURANCE