Hillsdale County Conserservation Club
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
You must also read and sign the release & indemnification from other side
Name ___________________________________________ Spouse__________________________________
City, Sate,& Zip Code _________________________________________________________________________
Phone__________________________E-mail__________________________________
For New Membership please provide two (2) references (one a current member of HCCC in order to be considered fore a membership
Name __________________________________________ Phone#_________________________________
Name __________________________________________ Phone#_________________________________
_____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 $___________
I/We would volunteer for______________________________________________________________
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OFFICIAL USE ONLY
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___
You must tell MUCC if you have ever been convicted of a conservation law violation or felony NO____ Yes_____
The Incident______________________________________________ Are You on probation? NO____  YES____
New Membership will be on (6) months probation
Type of Membership