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NAME:_________________________________

ADDRESS:______________________________

PHONE NUMBER:_________________________

E-MAIL:________________________________

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For Active Membership:

Member of which Fire Department?____________________

How Long Have You Been A Member?________________________

Valid Motorcycle License:_________________________

For Social Membership:

Active Member Sponsor?____________________________

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Please Mail completed application and a check for $20.00 to cover yearly dues to:
Chris Lafountain
265-A Cemetery Road
Plattsburgh, NY 12901

**Please make checks out to RKMC 34 c/o Ron Jarvis**