Name:                           

First_______________________________  MI______  Last___________________________________

Spouse's Name:

First_______________________________  MI______  Last___________________________________

Company Name: _____________________________________________________

Address: _______________________________________________________

City, State, Zip: ________________________________________________________________

Phone           

Home: (       )           -

Work:  (       )           -

E-Mail: ___________________________________________________

Type of Amputation: ___________________________________________

Disabled Veteran?     Yes _____     No _____

Date of Birth: ________________________
 

Annual Dues (Regular Member): $25 ______

Annual Dues (Non-Amputee, Associate Member): $35 ______

Life Membership fee structure: 

       Under age 25     $800 _____
       26-35                 600 _____
       36-45                 500 _____
       46-55                 400 _____
       56-65                 300 _____
       66-75                 200 _____
       Over age 75        100 _____

Golfers under the age of 18, and those between 18-24 attending college, 

pay no entry fee to the National Championship.

______ Please send information about NAGA and its programs. 

Call 800-633-NAGA (6242) for more information.

Dues payable in United States dollars.
Make check payable to NAGA.

Please check the appropriate areas and return this form to the NAGA.

NAGA

ATTN: Bob Wilson, Executive Director
11 Walnut Hill Road
Amherst, NH  03031-1713