National Rifle Association   NRA Recruiter C012864G

Membership Application                Southeast Louisiana Firearms Safety, Inc.

DATE: _______________NEW MEMBERRENEWAL # _________________________

NAME: Mr./Mrs./Ms. __________________________________________________________

STREET: ____________________________________________________________________

CITY: ____________________________________ STATE__________ ZIP_______________

DAY PHONE: (________) ___________________ BIRTHDATE: _______________________

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CHOOSE ONE MAGAZINE (Note: JUNIOR members receive Insights magazine)

AMERICAN GUARDIANAMERICAN RIFLEMANAMERICAN HUNTER

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MEMBERSHIP TYPE

1 YEAR $25  2 YEAR $60  3 YEAR $85  JUNIOR (under 21 years old) $15

DISTINGUISHED (age 65+ or disabled veteran) $30  LIBERTY (no magazine) $10

EASY-PAY-LIFE $25* (*$25 down-29 quarterly paymets-$750 total)

LIFE (payment in full) $750  ADDITIONAL MAGAZINE ($15 per year)

FOREIGN POSTAGE ($5 Canada, $10 other)  DONATION $_____

TOTAL COST DUE $_____

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PAYMENT INFORMATION  CHECK OR MONEY ORDER (payable to National Rifle Assoc.)

CHARGE TO: AMEX  VISA  MC  DISCOVER

ACCOUNT #_____________________________________________EXP. DATE_______________

MEMBER SIGNATURE_____________________________________________________________

Contributions, gifts, or membership dues made or paid to the National Rifle Association of America
are not refundable or transferable and are not deductible as charitable contributions for Federal
income tax purposes.

PRINT FORM, COMPLETE (PLEASE PRINT), AND MAIL TO:

National Rifle Association, Recruiter Program Department, 11250 Waples Mill Rd., Fairfax, VA 22030