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Registration Form

First Name:

Last Name:

Address:

(Optional Line 2):

City:

State:

Zip:

Phone:

Membership:

Type:	Junior	Single	Family
1 Year:	$1	$15	$20
3 Year:		$45	$60

Checks should be made out to Blackhawk Musky Club.
Please send your annual membership fees to:

Blackhawk Musky Club
P.O. Box 664
Janesville, WI 53547

Membership Year Expires December 31, 2008