*Type of application:  new renewal update  

*Type of membership:  single family single senior family seniors junior   

Date (if mailing application):

*Payment Method:
Check by Mail  Credit Card Online Cash at Meeting  

Amount Enclosed (if mailing application): $

*Name(s): 

Aviary/Company Name:

*Street Address: 

*City:   
*State:  IL FL IA IN MO WI XX   *Zip: 

Day Phone (XXX-XXX-XXX):    

Evening Phone:   

email:

Do you (check all that apply):
Own pet(s)?
Breed birds?  
Show birds?

Do you (check all that apply):
Sell at fairs?  
Sell to pet shops?  
Sell privately?

How many birds do you have?
(estimate if too many to count):

Bird Species: 

Important:  Every few years, the club prints a directory for the use of members.  Do you want to be listed in the next directory?  Yes   No   

If you just want your name and phone and not address, or not bird species, or just name and bird species, please state exactly what you want listed below.  This directory is sometimes used by members to find a mate for a bird or to talk to someone who has the same species.  If you are not willing to talk to other bird people, do not list your phone number below.  If all information is okay to print, select All.  If only specific items are okay to print, please list them.

What information do you want printed in the next directory:
All  Name and interests only  List Below:

The following information is for organizational use only and will not be printed in the directory.

What GCCBC committees or activities interest you? (Select one or more.)
Adoption Bulletin Fairs Hospitality Library Membership Publicity Shows Web Site

Would you be willing to foster birds?  Yes   No

What is your occupation? 

Do you have special talents or interests? 

Submit Application to Membership Chair.  Next page will provide instructions for payments.

Do Not Click Submit More than Once.