WESTERN BUFFALO SOLDIERS ASSOCIATION, INC.
1201 E. MICHIGAN ST. TUCSON, ARIZONA 85714
PHONE/FAX: 520-294-4402
Membership Application and Contribution Form
Renewal: _____ New Member: _____ Contribution: _____ Group or Organization: _____
Date: __________ if renewing, please give current membership number if known __________
Name of Group or Organization: _________________________________________________
First Name: ________________________________________________ Contact Person _____
Last: ________________________________________________
Address: ________________________________________________________________________
City: ________________________________ State: __________Zip Code:__________
Phone Number ___________________ Gender (M) or (F) _____
E-mail Address ________________________________________________
Are you 18 years old or older? ____ Must be at least 18 to become a Full Member.
Are you 55 or older? ____ Full Members only are you retired? ____ Full Members only
MOTTO: Restoring, Reconstructing and Reliving the Past, so that it may be enjoyed in the Present, ensuring that it will be remembered in the Future. ©
Please make checks payable to WESTERN BSA, INC.
Annual Membership Your Individual Contribution
Type of Membership Level of Contributions
____Full Member$100.00 Private... $100.00 ____
____Associate... .. $50.00 Corporal.... $250.00 ____
____Renewal ... $50.00 Sergeant... $400.00 ____
Sergeant major.. $750.00 ____
Lieutenant... $1500.00 ____
____Contribution Amount: __________ Captain..... $2500.00____
All contributions are tax deductible minus any benefits Major..............$5000.00 ____
you might receive. Lieutenant Colonel....$10,000.00 ____
Colonel.....$15,000.00 ____
All New Members are required to read Articles of Incorporation and the Bylaws. I have read the Articles of Incorporation and bylaws ____. My answers are true and complete. I understand that if I am accepted, any false or incomplete statements in this application will be grounds for immediate termination of membership.
Date: _________ Amount enclosed _________ Applicant's Signature: _________________________
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OPTIONAL INFORMATION (Full Members only)
(This information will be used to help us see where your skills can best be used to help the Association) for groups or Organizations this section must be filled out by the contact or spoke person.
Education
High School
Name of School: ________________________________________________________
Location: ______________________________________________________________
Number of years attended: _____________
Did you graduate? __________ What year did you graduate? ____________
Technical School
Name of School: ________________________________________________________
Location: ______________________________________________________________
Number of years attended: _____________
Did you graduate? __________ What year did you graduate? ____________
College and Post Graduate
Name of School: ________________________________________________________
Location: ______________________________________________________________
Number of years attended: _____________
Did you graduate? __________ What year did you graduate? ____________
What degree? __________________________________________________________
Name of School: ________________________________________________________
Location: ______________________________________________________________
Number of years attended: _____________
Did you graduate? __________ What year did you graduate? ____________
What degree? ___________________________________________________________
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Employment History (Must be completed by Full Members)
Beginning with your most recent employment and working back in time, please give the following information: For groups or Organizations this section must be filled out by the contact or spoke person.
Employer: _______________________________________________________________
Address: _______________________________________________________________
Job Title: _______________________________________________________________
Duties: _______________________________________________________________
Dates of Employment: __________________
Employer: _______________________________________________________________
Address: _______________________________________________________________
Job Title: _______________________________________________________________
Duties: _______________________________________________________________
Dates of Employment: _________________
Employer: ______________________________________________________________
Address: ______________________________________________________________
Job Title: ______________________________________________________________
Duties: ______________________________________________________________
Dates of Employment: __________________
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Emergency Contact (Full Members Only) for groups or Organizations this section must be filled out by the contact or spoke person.
Please provide the names of two persons who may be contacted in case of an emergency.
Name: __________________________________________________________________
Address: ________________________________________________________________
Telephone no.: ______________________
Relationship: __________________________
Name: _________________________________________________________________
Address: _______________________________________________________________
Telephone no.: ______________________
Relationship: __________________________
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Additional information
Please tell us about any other training, education, skills or achievements that you feel can be an asset to the Association.
________________________________________________________________________________
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Statement of Medical Health
Do have any health problems that would prevent you from riding horses or participating in other physical activities? Yes _____ No _____ if your answer was Yes you may be ask for more details at a later date.
Medical Problem: __________________________________________________________________
My answers are true and complete. I understand that if I am accepted, any false or incomplete statements in this application will be grounds for immediate termination of membership.
Date: _______________________
Applicant's Signature: _________________________________________________
