Kentucky Mid-State Appaloosa Club
Membership Application or Renewal
Year_____________
DATE________
NAME______________________________________________ApHC#________
SPOUSE'S NAME____________________________________ ApHC#________
FARM/STABLE NAME_________________________________________________
ADDRESS____________________________________________________________
CITY, STATE, ZIP_____________________________________________________
HOME ( )____________________ WORK PHONE ( )____________________
E-MAIL ADDRESS__________________________________________
WEBSITE__________________________________________________
CHILDRENS' NAMES BIRTH DATE ApHC YOUTH #
IF 18 & UNDER JAN. 1ST
___________________________ ____________ ______________
___________________________ ____________ ______________
___________________________ ____________ ______________
___________________________ ____________ ______________
Please check one: Single Membership $15 ___
Family Membership - $20 ___
(Includes Youth 18 & Under)
Would like to be involved in the following areas: (please check)
___Membership ___Futurity ___Youth
___Fundraising ___Marketing ___Newsletter
___Show ___Trail Riding ___Pointkeeper
Please make checks payable to KY Mid-State ApHC.
PLEASE SEND ME THE FOLLOWING NOMINATION FORMS IN ORDER TO BE
ELIGIBLE FOR YEAR-END AWARDS: ___Youth ___Open ___Non-Pro
SEND TO: PAULA GATEWOOD
4470 JONESVILLE ROAD
DRY RIDGE, KY 41035
