Application for Transfer of Club Membership

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: _______________________________________________________________

This transfer is only for current USMS members who want to affiliate with the North Carolina Masters Swimming Club (Club Number 1) and any of its associated chapters, PEAK Masters (Club Number 2), or unattached within the LMSC of North Carolina, please make a check payable to LMSC for NC for $3.00 and mail to:

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

North Carolina Masters Swimming Website
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Created: 8/31/98