WINDING BROOK SHOOTING RANGE LLC (804) 368-8540

DATE:________________

FIRST NAME: __________________________M.I.________LAST:____________________________

SPOUSE/PARTNER(FOR FAMILY MEMBERSHIP)___________________________________________

ADDRESS:_________________________________________________________________________

CITY:__________________________STATE:_________________ZIP:__________________________

WORK PHONE:__________________________HOME PHONE:_______________________________

DATE OF BIRTH:__________________________E-MAIL_____________________________________

I HEREBY CERRIFY THAT THE INFORMATION CONTAINED ABOVE IS TRUE AND CORRECT. I AGREE THAT ALL

PARTIES NAMED HERIN SHALL AGREE TO ABIDE BY THE RULES OF WINDING BROOK INDOOR SHOOTING RANGE

_____________________________________________ _________________________________
APPLICANT SIGNATURE DATE

MEMBERSHIP PLANS AVAILABLE (INITIAL ONLY ONE)

***ALL MEMBERSHIP PLANS INCLUDE 6 GUEST PASSES***

______________ INDIVIDUAL MONTHLY FEE: $34.99

______________ FAMILY MONTHLY FEE: $44.99

FAMILY MEMBER & SPOUSE: MINOR CHILDREN MAY SHOOT WITH THEIR PARENTS SUBJECT TO LANE RESTRICTIONS. CHILDREN UNDER THE AGE OF 21 MAY SHOOT
ON THE FAMILY CARD IF THE 1) LIVE AT THE SAME ADDRESS AS THE MEMBER AND 2) PROVIDE A PICTURE ID WITH THAT ADDRESS:

______________ MILITARY/LEO/1ST RESPONDER INDIVIDUAL MONTHLY FEE: $29.99

DISCOUNT OFFERED TO FIRST RESPONDERS, MILITARY ACTIVE DUTY, RESERVE & RETIRED OR LAW ENFORCEMENT PERSONNEL WITH ARREST POWERS.

______________ MILITARY/LEO/1ST RESPONDER FAMILY MONTHLY FEE: $34.99

DISCOUNT OFFERED TO FIRST RESPONDERS, MILITARY ACTIVE DUTY, RESERVE & RETIRED OR LAW ENFORCEMENT PERSONNEL WITH ARREST POWERS, MINOR
CHILDREN MAY SHOOT WITH THEIR PARENTS SUBJECT TO LANE RESTRICTIONS. CHILDREN UNDER THE AGE OF 21 MAY SHOOT ON THE FAMILY CARD IF THE 1) LIVE
AT THE SAME ADDRESS AS THE MEMBER AND 2) PROVIDE A PICTURE ID WITH THAT ADDRESS:

______________ SENIOR INDIVIDUAL (AGE 62+) YEARLY FEE: $240.00

MUST BE 62+ ON START DATE.

______________ SENIOR FAMILY (AGE 62+) YEARLY FEE: $280.00

MUST BE 62+ ON START DATE, MINOR CHILDREN MAY SHOOT WITH THEIR PARENTS SUBJECT TO LANE RESTRICTIONS. CHILDREN UNDER THE AGE OF 21 MAY SHOOT
ON THE FAMILY CARD IF THEY 1) LIVE AT THE SAME ADDRESS AS THE MEMBER, 2) PROVIDE A PICTURE ID WITH THAT ADDRESS, AND 3) PAY A $50 ANNUAL ADD ON
CHARGE.

______________ SENIOR INDIVIDUAL (AGE 62+) MONTHLY FEE: $20.00

MUST BE 62+ ON START DATE.

______________ SENIOR FAMILY (AGE 62+) MONTHLY FEE: $24.00

MUST BE 62+ ON START DATE, MINOR CHILDREN MAY SHOOT WITH THEIR PARENTS SUBJECT TO LANE RESTRICTIONS. CHILDREN UNDER THE AGE OF 21 MAY SHOOT
ON THE FAMILY CARD IF THEY 1) LIVE AT THE SAME ADDRESS AS THE MEMBER, 2) PROVIDE A PICTURE ID WITH THAT ADDRESS, AND 3) PAY A $50 ANNUAL ADD ON
CHARGE.
 WINDING BROOK SHOOTING RANGE LLC (804) 368-8540

ONGOING MEMBERSHIP PAYMENT INFORMATION

***RECURRING MEMBERSHIP BILLING OCCURS ON THE 1ST OF EVERY MONTH***
CREDIT CARDS
(STANDARD CREDIT CARDS ONLY. NO PREPAID CARDS MAY BE USED FOR ONGOING PAYMENTS)

NAME AS IT APPEARS ON CARD:_________________________________________________

CARD TYPE: AMEX______ VISA______ MASTERCARD_______

ACCOUNT NUMBER:__________________________________________________

EXPIRATION DATE: MONTH:_______________ YEAR:__________________

CVVS:___________
ACKNOWLEDGE AND RELEASE:
THE UNDERSIGNED DECLARES THAT THE STATEMENTS MADE HEREIN ARE FOR THE EXPRESS
PURPOSE OF OBTAINING ANY OF THE FOLLOWING: EFT, CREDIT CARD, MERCHANT ACCOUNT,
GATEWAY SET-UP AND GETTING SETUP WITH FINANCIAL PROCESSING COMPANIES, AND ARE
TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE AND CORRECT. THE APPLICANT
EXPRESSLY GRANTS PREMISSION FOR ALLIANCE PAYMENT TECHNOLOGIES INC AND E-ONLINE
DATA TO OBTAIN INFORMATION REGARDING THE PERSONAL AND BUSINESS HISTORIES
REFERENCED IN THIS APPLICATION WHICH INCLUDES BUT IS NOT LIMITED TO PERSONAL AND
BUSINESS CREDIT HISTORIES AND PUBLIC RECORDS SEARCHES CRIMAL RECORD SEARCHES,
BANK AND TRADE VERIFICATIONS, AND OTHER RISK ANALYSIS AS DEEMED NECESSARY. THE
APPLICANT UNDERSTANDS THAT ADDITIONAL INFORMATION MAY BE REQUIRED
CONSIDERATION CAN BE GIVEN TO THIS APPLICATION

_______________________________ _______________________________
SIGNATURE DATE
 WINDING BROOK SHOOTING RANGE LLC (804) 368-8540

Winding Brook Indoor Shooting Range

****CANCELLATION TERMS****

If the membership is cancelled at any time

prior to the 12 month/calendar year
commitment; a termination fee equal to 50%
of remaining months will be due at the time
of cancellation.

___________________ _______________
Signature Date