Name:______________________________________

Junior $5.00____ Indv.$8.00___ Family $12.00___

Address:_______________________________ City:_________________ State:_____

Zip Code:__________ Phone:________________ Email:____________________

What Breeds do you Raise?____________________________________________________________

____________________________________________________________

Send one year's dues to:

Jacob Bates, Secretary
C/O Heart of the Ozarks Poultry Club
614 N. Hancock. St.
Charleston, AR 72933
Phone: (479) 965-5222
Email: jakeab42@hotmail.com