Peacock Bass Association

www.peacockbassassociation.com Executive Director: Larry Larsen Contact Us!

Membership Form - Individuals

YES, I want to join the PBA!

Membership valid for one year to the nearest calendar quarter.
 If paying by check, print the completed form and mail to the address below. If paying by credit card, you may click the submit button below, mail to the address above or fax the complete form to (863)644-3288

•   1-year StandardMembership  $34.95
  (Renewal dues $29.95)
•   ($39.95 if B&W newsletter by mail) includes decal and patch.
  (Renewal dues $34.95)
•   1-year Premium Membership $54.95
  (Renewal dues $49.95)
  includes decal and patch plus your choice of either the DVD OR two of the following items - T Shirt, book or cap
•   3-Year Standard Membership $99.95
  (Renewal dues $89.95)
  includes decal and patch plus your choice of either the DVD OR two of the following items - T Shirt,  book or cap
•   3-Year Executive Individual Membership  $129.95
  (Renewal dues $129.95)
  includes $250 Trip Discount Certificate with selected agents/outfitters
  Click Here For Details 

    Renewal or 3-yr. Extension - Current Members check here
Add your  Membership Number (if available)  

First Name      
Last Name
Company

Address (as it appears on your credit card statement)

City State Zip

Phone Fax

email address (Important)  You will receive full color newsletter via e mail.
 
                I don't have an e mail address. I will pay $39.95 for standard membership to receive the B&W newsletter by U.S. mail

  Once my membership is acknowledged, I will call for my free 5-minute consultation with Larry Larsen.

If you have selected 1 Year Premium or the 3-Year Standard Membership, please check your choice below:

1. DVD -  
   OR two of the following
2. T Shirt -   TS1 Explosions!      TS2 Addiction
                   Size         M          L         XL   or     XXL
3. Book     PF3   PF4      or
4. Peacock Bass Cap 

Signature_____________________________________________
Submitting this form authorizes PBA to charge my card for my membership fee above. If you prefer, you may submit this completed form and provide your credit card information by fax or phone.