Name___________________________________________________________________________
Alias____________________________________________________________________________
SASS#__________________________________________________________________________
NRA#___________________________________________________________________________
Address__________________________________________________________________________
City__________________________________________State_____________Zip_______________
Telephone(H)_____________________________(W)_____________________________________
E-Mail Address____________________________________________________________________
Emergency Contact_________________________________________________________________
Emergency Phone#(H)______________________(W)_____________________________________
Allergies__________________________________________________________________________
Doctor's Name_____________________________________________________________________
Hospital Preference_________________________________________________________________
New Membership________Renewal____________
Membership dues of $25. per year. Please make check out to Southern Missouri Rangers

Signature_______________________________________________Date______________________

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Jeff Dunaway /SMR
672 E. Farm Rd. 20
Pleasant Hope, Mo. 65725
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