Green Mountian Prospectors of Vermont Membership Application

Name: ____________________________________________

Address: __________________________________________

__________________________________________________

Age: _____

Telephone number: ______________________

Email address: ____________________________________

*GPAA Membership number: ________________

*LDMA Membership number: ________________


Are you interested in: (check all that apply) panning ___ sluicing ___ high banking ___

dredging ___ crevicing ___ nugget shooting ___ lode mining ___


Would you be interested in: (check all that apply) becoming a club officer ___ helping with events ___

fund raising ___ legislative lobbying ___ equipment manager ___ web site administration ___

prospecting instructor ___ potluck coordinator ___ donations coordinator ___

raffle coordinator ___ just showing up ___


Please list a few of your other interests/hobbies:

______________________________________________________________________________________

______________________________________________________________________________________


Please let us know if you have any special accommodations we can help with:

______________________________________________________________________________________

Please send application to:

 Terry Fay

 399 Twitchells Settlement

 Rochester, Vermont 05767