Pa. State Hunters Organization Chapter No. 1

        246 Meadow Grove Rd.

      P. O. Box 415

                                   Newport, Pa. 17074                               

Ph. 717-567-3305

Coyote Hunt Application

Name: _______________________________Male __Female __

  Address______________________________________________

 City ______________________________State ____ZIP_______

   Telephone_____________________________________________

Email Address_________________________________________

Date of Birth ___________________Occupation_____________

Where did you hear about our club? ______________________

Are you a member of any other clubs or organizations? If so, which ones:

1)______________________2)__________________________

3)______________________4)__________________________

Waiver* I will not hold PSHO #1 responsible for any accidents or injuries due to  the Coyote Hunt_____(please initial)

Date_____________

Applicant’s signature_________________________________

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