Granite State Wheelmen
New Member and Renewal Application

For renewals, please include your Pedal Talk address label or membership number. 

---  PLEASE PRINT  --- 

Name(s) _____________________________________________________________

Address ______________________________________________________________

City ______________________________ State _________ Zip _________________

Telephone (___) ____________ E-mail ____________________________________

Emergency name and phone number _______________________________________

Your interests: On road __ Off road __ Tandem__ Commuting__ Recumbent__

May we list your phone number in our directory? Yes__ No__

I (We) will not hold the Granite State Wheelmen, Inc., its officers or members responsible for any injury or damages incurred while participating in any club function.

Signature 1 ____________________________

Signature 2 ____________________________ (parent or guardian if under 18)

Membership rates per household. Please indicate your selections:

New______ Renewal_____ Membership number __________

Bi-monthly newsletter delivery option desired:

1 year "electronic" $15_____ or 1 year "paper" $25 ______

3 year "electronic" $40_____ or 3 year "paper" $70 ______

Optional "dual delivery" at the $25 or $70 "paper" levels _____

New memberships includes one window decal.
Extra decals are $1.50 each.

Make check payable to and mail to:

Granite State Wheelmen, Inc.
215 South Broadway # 216
Salem, NH 03079-3322