Application for Transfer of Club Membership

please clearly print the following information:

Name: ______________________________________________________________

Address: ____________________________________________________________

City: ____________________________________ State: ______ Zip: ___________

Phone: ( ____ ) ____________ Birthdate: ___/____/____ Age: _______Sex: _____

Current Registration Number: ________________________

I hereby certify that it has been at least 60 days since I last completed for my former club

Signature: ________________________________________ Date: _____/ ______/ ______

Former Club Number: __________ Former Club Name: ______________________________

New Club Number: _____________ New Club Name: ________________________________

North Carolina Masters Swimming Chapter _________________________________________

e-mail address: _______________________________________________________________

note: your email address will only be used for LMSC for NC communications

This transfer is only for current USMS members who want to affiliate with the North Carolina Masters Swimming Club (Club Number 1) and/or any of its associated chapters, or unattached within the LMSC of North Carolina.

Please Check One: I want to receive my NC and RAM Newsletter by e-mail _____ or by hard copy via bulk Postal Bulk Mail ____

Please make a check payable to LMSC for NC for $3.00
Please make a check payable to RAM for $13.00 if transferring your membership to Raleigh Area Masters

Please include a photocopy of your current USMS Registration Card and mail to:

George S. Simon
Registrar, LMSC for NC
10229 Boxelder Dr
Raleigh, NC 27613-6139

Return to Masters Swimming in North Carolina's home page.
May 3, 2006
http://www.NCmasters.org/forms/transfer.html