WAGA Membership Application/Information Request

WAGA Membership Application
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Today's Date ____________________

Name: __________________________________ Spouse Name _____________

Company Name: ___________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Phone: ___________________________________________________________

E-mail address _____________________________________________________

Type of Amputation: AK __ BK __ AE __ BE __ DBL _____ other _______

Disabled Veteran? Yes ___ No ___ Date of Birth: ________________

USGA index ________ USGA organization _____________________________

GHIN Number _______________ Home Club ___________________________

Annual Dues (WAGA Regular Member):                      $20 ______
Annual Dues (Non-Amputee, Associate Member):        $20 ______
WAGA Lifetime membership                                   $150 ______
Junior Membership (Under the age of 18) - No annual dues __

Dues payable in United States dollars.
Make check payable to WAGA.

Please check the appropriate areas and return a check with this form to:
Western Amputee Golf Association
Membership Office
5980 Sun Valley Way
Sacramento, CA 95823 427-0559