|
Full Name: |
|
|
|
|||||||||||||
|
Last (Family Name) |
First (Given Name) |
M.I. |
||||||||||||||
|
Address: |
|
|
|
|||||||||||||
|
Street Address |
Apartment/Unit # |
|
||||||||||||||
|
|
|
|
|
|
||||||||||||
|
City |
State |
ZIP Code |
|
|||||||||||||
|
Home Phone: |
|
Alternate Phone: Office Cell |
( ) |
|
||||||||||||
|
E-mail Address: |
|
|
||||||||||||||
|
List in Members ONLY Club Directory? (Please circle) |
Yes No |
|
||||||||||||||
|
Newsletter (5/yr) by: (Please Circle) |
Paper E-Mail (Saves ~ $5.00 of dues for other things) |
|
||||||||||||||
|
Years Keeping Honeybees? County You Keep Hives and Number Hives? |
|
|||||||||||||||
|
Would you be willing to speak to non-beekeeper groups about honeybees and beekeeping? (Please Circle) Yes No |
|
|||||||||||||||
If Yes, (Please circle & fill) Day Evening Weekend Within ___ Miles of home address.
|
|
|||||||||||||||
Apiary(ies) |
|
|||||||||||||||
|
Location |
# of Hives |
|
||||||||||||||
|
Location |
# of Hives |
|
||||||||||||||
|
|
|
|||||||||||||||
Membership & Subscriptions |
|
|||||||||||||||
|
BANV 2010 |
Beekeepers Association of Northern Virginia – January 1- December 31, $20.00/yr/Household Includes $10 Virginia State Beekeepers Association membership, July 1, 2010 – June 30, 2011. NOTE!!: If State dues paid through another VA club or not a VA resident, deduct $10 |
|
|
|||||||||||||
|
|
|
|
|
|||||||||||||
|
|
|
|
|
|||||||||||||
|
|
Check Number: |
Bank: |
TOTAL $ |
|
|
|||||||||||
|
|
|
|||||||||||||||