DSI MEMBERSHIP APPLICATION - NEW YORK STATE RESIDENT

Name:_________________________________________________________

Date of Birth:____________________ Age:________

Address: __________________________________________________________________________________

__________________________________________________________________________________________

Telephone:____________________ Fax:______________________ E-mail: _______________________

Occupation: ___________________

D.E.C. Region # you reside in:_______________________________

Type of Membership: Regular ___     Supporting ___     Junior ___

Do you belong to any Gun Clubs? YES / NO

If YES give name or names _______________________________________________________

Have you ever been suspended from a Gun Club? YES / NO

If YES give name or names _______________________________________________________

Do you have a hand gun permit? YES / NO

Have you ever applied for a hand gun permit? YES / NO

If permit was denied please give reason: _____________________________________________

Do you hold a New York State Guides License? YES / NO

Why do you want to become a member of Deer Search? ____________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Recommending DSI Member's Name (optional) __________________________________________________

Give the names/addresses/phone numbers of three (3) references:

l. __________________________________________________________________________________

2. __________________________________________________________________________________

3. __________________________________________________________________________________

Have you ever been convicted of a Game Law violation? YES / NO

[ print your name ]

I, ……………………………………………………consent to have the Law Enforcement Division of the New York State Department of Environmental Conservation make a recommendation concerning any history of law violations I incurred which might be incompatible with Deer Search activities.

_____________________________________________________________________

(signature)                                                                                             (date)

Fees Due with Application (make check to Deer Search Inc.)

$10.00 Application Fee and $15.00 Dues for Regular Membership (total $25.00)

OR 

$10.00 Application Fee and 25.00 Dues for Supporting Membership (total $35.00)

• If you are applying to the Founding Chapter send your application along with the check to:  P.O. Box 853, Pleasant Valley, NY 12569
• If you are applying to the Western New York Chapter send your application along with the check to:
  Deer Search of WNY, PO Box 251, Lancaster, New York 14086
• If you are applying to the Western New York Chapter send your application along with the check to:
  Deer Search of the Finger Lakes, P.O. Box 45, Gainesville, NY 14066
   

Thank you for applying

_________________________________________________________________________________________

To be filled out by Chairman of the Membership Committee:

Date of reading:

Date of investigation:

Date voted on:

Approved: YES / NO