Hillsdale County Conserservation Club
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Please fill in all applicable information,even if you are just renewing and either return it to the HCCC
representative from whom you obtained it or send it to.
HCCC treasurer Peggy LoPresto 5511 Bowditch Road Osseo MI.49266
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You must also read and sign the release & indemnification from other side
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Name ___________________________________________ Spouse__________________________________
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City, Sate,& Zip Code _________________________________________________________________________
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Phone__________________________E-mail__________________________________
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For New Membership please provide two (2) references (one a current member of HCCC in order to be considered fore a membership
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Name __________________________________________ Phone#_________________________________
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Name __________________________________________ Phone#_________________________________
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_____Family (2 adults & all children under 18 years of age)-$50 _____Senior(65& up)-$35
____ Junior (under 18) - $20 _____ Life (fill in age & amount from chart from below _____ $________
<30=$700 30-40 = $650 40-50 = $600 50-60 = $550 60-70 = $500 70-80 = $450 >80=$400
Do you want to receive the MUCC magazine Michigan Out-of -Doors? NO_____ YES____ if so the discounted Club
rate($20) will be added to your dues
TOTAL DUES $___________
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I/We would volunteer for______________________________________________________________
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Submitted/Rec'd By__________________________ Date-______/______/ 20______
Treas rec'd Date-____/_____/ 20_____ Amt=$__________ Cash / Check#_______
Sec. Rec'd App ___/___/20___ Board Approval-___/___/ 20___ Card given / sent ___/___/ 20___
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You must tell MUCC if you have ever been convicted of a conservation law violation or felony NO____ Yes_____
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The Incident______________________________________________ Are You on probation? NO____ YES____
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New Membership will be on (6) months probation
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