FSHPA INC. MEMBER INFORMATION

NHPA DUES ARE $17.00 AND STATE DUES ARE $10.00

NAME: _________________________________________________ NHPA NUMBER ____________________

FLORIDA ADDRESS: __________________________________________________________ YEAR ________

CITY: _______________________________________ STATE: _____ ZIP CODE: ____________________

SEND NEWSLETTER TO ABOVE ADDRESS FOR ISSUES (CIRCLE THOSE THAT APPLY) MAR JUN SEP DEC

DATE OF ISSUE IS FIRST DAY OF INDICATED MONTH. IF YOU WANT DELIVERY OF NEWSLETTER THROUGH FLORIDA’S WEB SITE CIRCLE HERE WEBSITE DELIVERY IF CIRCLED NO HARD COPY WILL BE MAILED TO YOU.

FLORIDA PHONE NUMBER _____________________________________________

OUT OF STATE ADDRESS: _____________________________________________________________________

CITY: _____________________________________________________ STATE: ______________ ZIP CODE: ____________________

SEND NEWSLETTER TO OUT OF STATE ADDRESS FOR ISSUES (CIRCLE THOSE THAT APPLY) MAR JUN SEP DEC

ABOVE LINE DOES NOT APPLY IF YOU CHOOSE TO RECEIVE THE NEWSLETTER THROUGH THE FLORIDA WEB SITE.

STATE OF LEGAL RESIDENCY ___________ NUMBER YEARS NHPA MEMBER _______________-

CIRCLE CATEGORY BELOW THAT APPLIES TO YOU

MALE PITCHING 40 FEET HANDICAPPED MALE PITCHING 30 FEET ELDER MALE PITCHING 30 FEET

WOMAN PITCHING 30 FEET JUNIOR BOY PITCHING 30 FEET JUNIOR GIRL PITCHING 30 FEET

BIRTH DATE IF JUNIOR BOY OR GIRL ___________________________

SPONSORED BY:_________________________________________________

RETURN TO: JOHN PEPLINSKI 3550 BOBWHITE CT. MELBOURNE, FL 32904

FSHPA INC. MEMBER INFORMATION

NHPA DUES ARE $17.00 AND STATE DUES ARE $10.00

NAME: _________________________________________________ NHPA NUMBER ____________________

FLORIDA ADDRESS: __________________________________________________________ YEAR ________

CITY: _______________________________________ STATE: _____ ZIP CODE: ____________________

SEND NEWSLETTER TO ABOVE ADDRESS FOR ISSUES (CIRCLE THOSE THAT APPLY) MAR JUN SEP DEC

DATE OF ISSUE IS FIRST DAY OF INDICATED MONTH. . IF YOU WANT DELIVERY OF NEWSLETTER THROUGH FLORIDA’S WEB SITE CIRCLE HERE WEBSITE DELIVERY IF CIRCLED NO HARD COPY WILL BE MAILED TO YOU.

FLORIDA PHONE NUMBER _____________________________________________

OUT OF STATE ADDRESS: _____________________________________________________________________

CITY: _____________________________________________________ STATE: ______________ ZIP CODE: ____________________

SEND NEWSLETTER TO OUT OF STATE ADDRESS FOR ISSUES (CIRCLE THOSE THAT APPLY) MAR JUN SEP DEC

ABOVE LINE DOES NOT APPLY IF YOU CHOOSE TO RECEIVE THE NEWSLETTER THROUGH THE FLORIDA WEB SITE.

STATE OF LEGAL RESIDENCY ___________ NUMBER YEARS NHPA MEMBER _______________-

CIRCLE CATEGORY BELOW THAT APPLIES TO YOU

MALE PITCHING 40 FEET HANDICAPPED MALE PITCHING 30 FEET ELDER MALE PITCHING 30 FEET 70+

WOMAN PITCHING 30 FEET JUNIOR BOY PITCHING 30 FEET JUNIOR GIRL PITCHING 30 FEET

BIRTH DATE IF JUNIOR BOY OR GIRL ___________________________

SPONSORED BY:_________________________________________________

RETURN TO: JOHN PEPLINSKI 3550 BOBWHITE CT. MELBOURNE, FL 32904