Name:________________________________________________________ DOB Month___ Day___

Name:________________________________________________________ DOB Month____Day___

Address:____________________________________________________________________________

City/State/Zip________________________________________________________________________

Phone:_(____) _________________ E-Mail _______________________________________________

Jr. League Member : Under age 18

Name:________________________________________________________ DOB Month___ Day___

Would you object to your Name, Address, Phone or E-Mail being listed in the club Directory? Yes___ No__

Do you presently own koi? ___ , Do you presently have a pond? ____ Or an aquarium? _________

Would you be interested in any of the following? ( Check all that apply)

Hosting a meeting  ____, Being on a committee____, Showing your pond ____, Showing your fish ____

Would you  like the club to assign an experiencd koi keeper to serve as your a mentor? Yes___No ___

Member Benifit Listing:  The club will be publishing a listing of members,  member businesses, skills and specialized knowledge to give members a reference when making purchase or needing advice and for the purpose of finding your personal interests in the hobby and specialty skills. Do you have specialized knowledge of subjects such as koi health, breeding, plants, chemicals, filters, pond building, electrical, plumbing, concrete or any other area which you feel would be of interest. ______________________________________________________ _____________________________________________________________________________________