Jackson, Maine


Please print clearly and answer all questions.  Incomplete or illegible applications will be returned.


Name:                                                                                                     __________________________________ 

                                            First                                  MI                                Last                                                             

Address:                                                                                                                                                                    _

                                                Street                                                               City                                      State                                    Zip

Home Phone: (       )                                                         Work Phone: (       )                                                           

Email address:_____________________________________

NRA Member Number (See discount below)                    ___________    Expiration Date                                 __

PD affiliation (if any):_________________________

Person who referred you to the club (if anyone):____________________________


Dues for Members

The annual dues are twenty-five dollars ($25.00) for current NRA Members.

The annual dues are sixty dollars ($60.00) for Non-NRA Members.*

*An NRA membership is $35.00 annually. The non-NRA membership dues DO NOT include an NRA membership through your enrollment in the Great Farm Rifle Club.

I certify that I am not a member of any group or organization that advocates the overthrow of the government of the United States of America and that I have never been convicted of a felony or a disqualifying conviction for domestic assault. I further certify that if admitted to membership I will faithfully endeavor to fulfill the obligations of good sportsmanship and citizenship and I agree to fully abide by the rules, regulations and by-laws of the Great Farm Rifle Club. I fully understand that an untruthful statement to the above is just cause for revoking my membership.

 Applications will be reviewed and voted on by club officers. Subsequent pending applicants will be required to attend a range safety assessment and orientation given by the appointed officers of the range. Pending applicants will be notified of an appointment time to meet with range officers.

My submission of this form implies that I have read and understand this form and the attached range rules and will abide by the rules of the range should my membership be approved.

Signature:                                                                                 Date:                                    __


Mail to:           Great Farm Rifle Club

PO BOX 345

Brooks, ME 04921