MEMBERSHIP APPLICATION

ASSOCIATION FEE $5.00 Per Year

1 Yr ___ 2yr ___ 3 yr ___ 4 yr ___ 5 yr ___

NAME ______________________________________

Region ________ School District ________________________

Complete the appropriate information

HOME ADDRESS _____________________________________________  CITY  _____________________________ KY  ZIP _________ 

OR

WORK ADDRESS _________________________________________________ CITY ___________________________ KY  ZIP _________

Phone number & e-mail address for contact

PHONE # (______) ________________ EXT ______ Cell( _____)_____________ FAX # (_____) _____________

EMAIL    ___________________________@____________________________________________

SIGNATURE __________________________________________ Date _____________

Check appropriate spaces/spaces

Driver Trainer ___ Transportation Director ___ Mechanic ___ Secretary ___ Other ___ Specify _______________

______________________________________________________________________________________________

DO NOT WRITE BELOW ASSOCIATION INFORMATION ONLY

   1 yr ____     2 yr _____     3 yr _____     4 yr _____     5 yr _____

DATE RECEIVED ___________/___________/ 200 ______    MEMBERSHIP # _______________

PAID BY:      CASH ________________      CHECK # _______________________

SIGNATURE OF PERSON RECEIVING FUNDS _________________________________________

Mail to

David Jones

 90 Parnell Rd.

 Columbia, 42728

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