Today's Date  ________________

Your Name  ________________________________  Birthdate  ____________

Spouse's Name _____________________________   Birthdate  ____________

Children under 18 living with you _____________________________________

_________________________________________________________________

Address  _________________________________________________________

City         _____________________________  State _________  Zip  _________

Home Phone  __________________    Work Phone  _______________________

E-mail  ___________________________         FAX   ______________________

NMLRA# _____________________  Expiration date ______________

NRA#      _____________________  Expiration date _______________
(this information is used to support our status as an NMLRA Charter Club and for NRA Insurance)

Received by (CPR member)  __________________________________