Gopher Wheelmen Mail Completed Form to: Membership Form Gabe Masiulis 2010 734 6th st E St Paul, MN 55106-5122 Please Print Please Print --------------------------------------------------------------------------------- Send My Membership form by [ ] Snail Mail [ ] Email Check one - Membership Renewal [ ] New Membership [ ] Dues are $20, Checks payable to Gopher Wheelmen Amount Enclosed ______ Name: (First) _________________________, (Last) ___________________________ Renewing Members need only indicate changes from last year's Membership Address: _________________________________________________________________ _________________________ __________ ______________ (City) (State) (Zip) Phone: (____) ______________ (_____) _______________ (_____) _________________ Home Work Mobile Phone Email Address: __________________________________________________________________ Do you hold a current racing or officiating license? USCF [ ] Yes [ ] No NORBA [ ] Yes [ ] No Road Cat _________ Track Cat __________ CycloCross Cat ___________ End/XC ___________ Gravity/DH _________ Mtn Cross/DS Cat __________ Official _________ Date of Birth: ____________ Gender [ ] Female [ ] Male Cycling Intrests: (Check all that apply) Racing: Road ______ Crits ______ TT _____ Track _____ MTB ______ Cross ______ Ultra _____ Multisport _______ Goals/Notes: _______________________________________________________________________________________________ All Members are expected to participate in volunteer work each year on behalf of the club Please List your volunteer efforts on behalf of the club for 2009 and the name of your Promoter/Coordinator: (Renewing Members only) ____________________________________________________________________________________________________________ What events are you interested in volunteering at for 2010?: Ken Woods Mem Road Race __________ Red Barn CX _______________ Other: _____________________________ ____________________________________________________________________________________________________________