East Montpelier Gully Jumpers -- Club Membership Application

Club Membership Application
East Montpelier Gully Jumpers
P.O. Box 75
East Montpelier, VT 05651
www.gullyjumpers.com

------------PLEASE PRINT/TYPE CLEARLY------------

	Club Membership	$12.00
	Grooming Donation

First Name (Club Member)	Middle Initial	Last Name

PO Box or House Number and Full Street Address, etc.

City/Town	State	Zip Code	+4

Telephone	Email	Age