Name: _______________________________________________________

Youth and Date of Birth: ___________________________________

Youth and Date of Birth: ___________________________________

Ranch Name: _________________________________________________

Address: _____________________________________________________

City, State, Zip: ________________________________________________

Phone: _______________________Fax/2nd Phone: __________________

Email Address: ________________________________________________

Web Address: _________________________________________________

New Member _____ or Renewal _____

Membership Dues are due 1/1/2012 and are valid through 12/31/2012

__$35.00/year - Single Membership, 1 vote, newsletters, all club and show mailings and full member privileges

__$40.00/year - Family Membership, 2 votes, newsletters, all club and show mailings and full membership privileges

CREDIT CARDS ACCEPTED

Please send this form and payment to:

NORCAL Miniature Horse Club Secretary- Card #______________________

Melissa Kovach

1276 4th Street Expiration___________________

Lincoln, CA 95648

Email: mtkovach@hotmail.com 3 digit security code__________

NOTE: 3% processing fee will be added if credit card is used

For more NORCAL MHC info go to http://www.norcalminiatures.com