| What It Is |  110 East Fayette Pittsfield, IL 62363 (217) 285-2464 fax (217)285-5121 Access Illinois Outdoors/Two Rivers Application Form Name______________________________________________________________Date_________________ Address_____________________________ City__________________________State_____ Zip__________ Home Phone____________________________ Work Phone_______________________________________ E-mail address: _________________________ Vehicle Make and Model______________________________________________Year__________________ License Plate Number_________________________ Please check the type of membership preferred, plus check the activities you wish to pursue. ____$25 annual membership for one person for all outdoor activities. ____$50 annual family membership (family living in same household). Checks payable to: Access Illinois Outdoors/Two Rivers
Please rank 1-8 your county choices: Adams___ Brown___ Calhoun___ Pike___ Schuyler___ Scott___ Greene___ Jersey___ Limited access counties: Carroll ___ Bureau ___ Cass ___ DeWitt ___ Fulton ___ Hancock ___ Hardin ___ Logan ___ Macon ___ Marshall ___ Mason ___ McDonough ___ Macoupin ___ Menard ___ Morgan ___ Randolph ___ Sangamon ___ Wabash ___ Please list names, addresses and phone numbers of members applying with you. (All persons participating must be a member of Access Illinois Outdoors/Two Rivers) __________________________________________________________________________________________ __________________________________________________________________________________________ On the back of this form, please provide a short narrative about yourself. (Years of outdoor experience, memberships in outdoor organizations, references, etc.) Mail to: Access Illinois Outdoors/Two Rivers, 110 E. Fayette, Pittsfield , IL. 62363 telephone: 217 285-2464 fax: 217 285-5121 e-mail: accessil@2riversrcd.org Web Site: http://www.2riversrcd.org/accessil |
