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					  Affiliated with the                                                                                           Member of the
   National Rifle
  Association since
      May 1917
                                     Pleasantville Rifle Club                                                   New York State
                                                                                                                Rifle and Pistol

                                         Application for Membership

Name: __________________________________________ Date: _______________

Address: _____________________________________________________________

Date of Birth: ___________ Home phone: _______________ Cell: _______________

E-mail: _______________________ Sponsoring Member: _____________________

Sponsoring Member’s signature: __________________________________________

Original pistol permit no. :______________ Present pistol permit no.: _____________

Occupation/Business/Profession: _________________________________________

Other rifle or pistol club affiliation: __________________________________________

NRA no.: _____________exp.____ NYSRPA no.: __________________exp. ______

            Please include copies of your pistol permit, NRA card and NYSRPA card.

                                                     RANGE RULES
    1.    Only people having a NYS pistol permit may handle and fire handguns.
    2.    Eye and ear protection must be worn on firing line.
    3.    Basic NRA safety rules must be complied with on the premises.
    4.    Range officer’s commands must be obeyed.
    5.    No alcohol or other intoxicating substances or anyone under the influence of same is permitted on premises.
    6.    Remove guns from your case or box on the firing line only. Muzzles pointed down range at all times.
    7.    Please sign in and out of range on provided sheet.
    8.    No smoking on the firing line.
    9.    Observe all other rules posted or verbally spoken in the range.

Utilization of these facilities may involve possible physical injury. I hereby assume all risk of injury arising from their use
and to hold blameless the Pleasantville Rifle Club, its officers, members and said range facilities.

I have read the above Range Rules and agree to abide by them. Any infraction may lead to expulsion from the club.

I certify that I am a citizen of the United States, 18 years or older; that I am not a member of any organizations which has,
or any part of its program, the attempt to overthrow the government of the United States by force or violence; that I have
never been convicted of a felony or crime of violence and that if admitted to membership will fulfill the obligations of good
sportsmanship and good citizenship.

Signature: ___________________________ print ____________________________ date:______________

Approval: ___________________________ print ____________________________ date:______________
Affiliated with the                                                                           Member of the
 National Rifle
Association since
    May 1917
                                Pleasantville Rifle Club                                      New York State
                                                                                              Rifle and Pistol

                                     Application Requirements

  1. Proof of membership in the NRA and the NYS Rifle and Pistol Association is required for
     application and annual Club membership renewal. The Pleasantville Rifle Club has
     applications for these organizations. We can assist you in joining.

  2. A sponsor from the membership of the Pleasantville Rifle Club is required.

  3. The applicant must be approved by the executive board.

  4. Application fee (one time fee) $100.00

             a. Included in this fee is processing of application, first year dues $15.00 and first year
                assessment $35.00

             (subsequent yearly dues are $15 and assessment $35 total $50 per year)

             Make checks payable to: Pleasantville Rifle Club

             Mail completed application and check for $100 along with appropriate copies of current
             pistol permit, NRA and NYSRPA membership cards to the secretary:

                               Marie Orser
                               303 East Lake Blvd.
                               Mahopac, NY 10541

             If you have any questions please call:

                               Jonathan Orser, President (845) 628-8010
                               Nick Michailidies, V. President (845) 878-4804

             Thank you,

             Executive Board

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