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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. ______________________________________________________ _____________________________________________________________________________________

Dues: $20.00 Single Membership, $30.00 Double Membership, Jr. League $5.00 each member

Dues are payable January 1st - Please use this form so we can update your information

Mail checks made payable to North Florida Koi Club or NFKC: Jan Brown, 2732 Connie Circle, Orange Park, Fl 32073                                                                                                          Date:_______________________

Sponsored By: __________________