MEMBERSHIP APPLICATION

South Mississippi Cage Bird Society

TYPE OF MEMBERSHIP:                New            or                      Renewal            Date:                           

FAMILY:             1 yr ($20)            SINGLE:              1 yr ($15)            ASSOCIATE:                  1 yr ($15)

NAME(S):                                                                                                                                 

                        (LAST)              (FIRST)                         (LAST)              (FIRST)

ADDRESS:                                                                                                                                

                                                (STREET OR APT.)

CITY:                                        STATE:                         ZIP:                             

TELEPHONE:      WORK (            )            -                       HOME            (            )            -          

                         CELL (            )            -                        PAGER            (            )            -          

EMAIL ADDRESS:                                                                                                                    

I am interested in the South Mississippi Cage Bird Society because:

             I have pet birds                                                I buy birds for resale

             I raise birds for show                                        I own or work in a pet store

             I breed birds as a hobby                         I breed birds commercially

             I am a veterinarian, vet student, or vet technician

             Other (Please specify)                                                                                                

List the bird species you have as a pet, have bred, show or other (Please specify)

I prefer to receive my monthly newsletter via                 U. S. Post or               email

I heard about SMCBS from:                                                                                                    

Other bird organization affiliations:                                                                                           

If you want privacy: Please do not include my                     name,    phone,              email address on the membership directory.

Make checks payable to:                    South Mississippi Cage Bird Society

Mail to:                                            PO Box 7012

                                                       d’Iberville MS., 39540