Membership Renewal Application – Office Use Membership Renewal Application-2021 Chester Rod and Gun Club, Inc. 99 Rod and Gun Club Road Chester, NH 03036 (603) 887-4629 www.chesterrodandgunclub.com Application for Calendar Year * Reviewed By: * B Paiva B Caldwell J Lattanzi P Donley J Stiles The Primary Member MUST renew this Membership.Renewals by the Spouse/Partner are not permitted. Change Alerts Renewal Information Membership Type * Single Family Student Senior Active Military Lifetime Police Membership Dues: Single $150.00 | Family $150.00 | Student $65.00 | Senior $75.00 (age 65) | Active Military - Lifetime - Police $0.00NOTES: LIFETIME Memberships are available by CRGC Award Only POLICE Memberships are available to Affiliated Police Organizations Only Include Spouse/Partner on Membership? * Yes No No additional fee. Spouse/Partner Full Access or Escort Only * Full Access Escort Only Will the Spouse/Partner Member require a full access badge (Orientation and Safety Training required) or an escort only badge (they must be escorted by a full member but are exempt from guest fees)? Primary Member Information FirstName * LastName * Member No. Gender * Male Female Date of Birth * Age You must be 65 or older to qualify for a Senior Membership. Please select a different membership type. Email * Phone * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Are you a US Citizen? * Yes No Are you a lawful permanent resident of the US? * Yes No What is your alien registration number? * Have you ever been convicted of a felony? * Yes No Do you have any outstanding warrants? * Yes No Have you ever been convicted of a domestic violence offense? * Yes No Have you ever had a membership refused or revoked at any gun club? * Yes No Are you presently under the restrictions of a restraining order * Yes No Are you now under any kind of indictment in any jurisdiction? * Yes No Are you a member of the NRA? * Yes No What is your NRA Membership Number? Are you a life member of the NRA? Yes No Spouse/Partner Member Information S/P FirstName * S/P LastName * S/P Member No. * S/P Gender * Male Female S/P Date of Birth * S/P Age One of the persons on this Application must be 65 or older to qualify for a Senior Membership. If you have made an error in either Date of Birth, please correct it. If not, please select a different membership type. S/P Email If you enter the same email as the Primary Member, this field will clear. If you don't have your own email address, leave this field blank. S/P Phone S/P Are you a US Citizen? * Yes No S/P Are you a lawful permanent resident of the US? * Yes No S/P What is your alien registration number? * S/P Have you ever been convicted of a felony? * Yes No S/P Do you have any outstanding warrants? * Yes No S/P Have you ever been convicted of a domestic violence offense? * Yes No S/P Have you ever had a membership refused or revoked at any gun club? * Yes No S/P Are you presently under the restrictions of a restraining order * Yes No S/P Are you now under any kind of indictment in any jurisdiction? * Yes No S/P Are you a member of the NRA? * Yes No S/P What is your NRA Membership Number? S/P Are you a life member of the NRA? Yes No Conditions of Membership I UNDERSTAND that I am not eligible to be presented for membership acceptance until I have attended the required orientation meeting, and firearms safety class, and have passed the range rules test. (new members only) I WILL be present at the meeting of my membership acceptance and provide photo I.D. (new members only) I HEREBY CERTIFY that I am not prohibited from possessing, selling, owning or transferring firearms under state or federal law. I have not been convicted of a felony that has not been annulled or expunged; I have not been convicted of a violation of 18 USC§ 922 that has not been annulled or expunged; and I am not a member of an organization that advocates the violent overthrow of the United States Government. I UNDERSTAND that I must present documentary evidence of my lawful ability to own firearms, per the ByLaws. Documents will be viewed and not retained, except for affidavits of eligibility. I WILL read and abide by The Chester Rod and Gun Club Constitution, By-laws, Range Rules and Policies. I will download the current year’s Range Rules from the Club’s web site each year and be familiar with all changes. I UNDERSTAND that I am responsible for anyone using Club facilities covered under my membership. I UNDERSTAND that I am prohibited from giving out any and all combinations, keys or access control badges to Club buildings and grounds. I UNDERSTAND I must have and visibly display my Membership Badge while on Club property, and must present it to any person on the property who requests it. I UNDERSTAND that all members are required to renew their membership by December 31st of each year. I UNDERSTAND that any misrepresentation on this application will result in termination of my membership without any refund of paid fees. I UNDERSTAND that by providing my/our e-mail address(es) I/we agree to allow the Club to add my/our e-mail address(es) to the Club’s e-mail list(s) and to send me/us e-mail notifications based on my/our configured preferences. The Club’s e-mail alerts will be used for club business only and the Club will not divulge your email address(es) to anyone outside the Club without your permission. IN CONSIDERATION of being allowed on the premises of CRGC or to participate in any activities at CRGC, I hereby voluntarily agree to assume any and all risks associated with shooting at CRGC. I understand the risks and hazards involved. Shooting may be considered a dangerous activity, with the risk of potentially life-threatening injuries, and potential exposure to lead and airborne lead particles. I assume the risk of any and all injuries I may suffer due to the physical condition of CRGC, the potential negligence of CRGC, equipment failures, defective equipment, acts of God, and the acts or omissions of shooters or others who may be at, on, or near, CRGC, whether with or without permission of CRGC. I agree to indemnify and hold CRGC harmless for any injuries. I HEREBY consent to receive medical treatment and be responsible for the payment of same, which may be rendered in the event of injury, accident, and/or illness during the activities at CRGC. I UNDERSTAND there will be other persons shooting and/or carrying firearms at CRGC, and I agree to act prudently and carefully to avoid causing them any injury. I certify that I am or will be familiar with the safe use and operation of any firearms I may use while at CRGC. I have read and I am familiar with the rules of shooting and firearm safety and hereby do agree to follow the CRGC Range Operation and Safety Rules (copies available). ON BEHALF of myself, my estate, my heirs, and assigns, I hereby release CRGC, their employees, agents, representatives, assigns, members, instructors, and volunteers from any and all liability regardless of cause, including injuries due to negligence, up to and including death, or due to property damage or theft I may suffer because of my presence and participation in activities at CRGC, which may be caused by my own or others' negligence. I specifically release CRGC for myself, my heirs and assigns from liability for any personal injury, death, disability, and acts and/or omissions of whatsoever kind and nature including, but not limited to, those caused by negligence including, but not limited to, those acts and/or omissions of other participants or persons at the CRGC shooting range(s). I UNDERSTAND that both commercial and non-commercial still, audio/video, and/or motion picture photography may occur during my presence on CRGC property and as long as I am in the general area, I may be incidentally included in such recordings. Should I wish to be excluded from such recordings, I understand that it is my responsibility to be aware of recording activity and remove myself from the area or event being photographed or recorded. Absent such action on my part, I hereby grand CRGC, its agents, volunteers, sponsors, beneficiaries, heirs, and assigns the right to use my photographic image and video/audio recording(s) in the promotion of the shooting sports or CRGC in general as it chooses in its sole discretion without compensation. IF ANY portion of this release is found to be invalid, the offending portion shall be stricken, and the remainder shall remain in full force and effect. I hereby agree that jurisdiction for any action pertaining to this liability release shall lie exclusively in Rockingham County, State of New Hampshire and shall be governed exclusively by the laws of the State of New Hampshire without reference to conflict of law provisions. BY SIGNING this waiver, I acknowledge the contagious nature of communicable diseases and voluntarily assume the risk that I may be exposed to or infected by communicable diseases by visiting the club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by communicable diseases at the club may result from the actions or omissions of myself and others, including, but not limited to, volunteers, participants, and club members. I/We complete and sign this application to Chester Rod and Gun Club knowing that my / our signature(s) constitute(s) my / our knowledge and understanding of, acceptance of, and agreement to ALL of the above statements. I / We further state that the information herein is to the best of my / our knowledge and ability to be true and correct. My / Our acceptance shall remain in force so long as I / We remain a member of the Club. My / Our drawn or typed Digital Signature(s) on this or any renewal membership application(s) delivered in electronic format shall have the same effect and force as my / our written signature(s). Primary Member Signature * Clear Select the pencil icon to draw your signature or the keyboard icon to type your signature. Spouse/Partner Member Signature * Clear Select the pencil icon to draw your signature or the keyboard icon to type your signature. Submission Date * If you have not previously presented documentary evidence that you are not prohibited from owning firearms you must do so either in person to a CRGC Officer or Director or by uploading your document here. For a list of acceptable types of documentary evidence, please see the New or Renewing Membership pages on the CRGC website. Upload Primary Member Documentary Evidence Drop a file here or click to upload Choose File Maximum upload size: 1MB Upload Spouse/Partner Documentary Evidence Drop a file here or click to upload Choose File Maximum upload size: 67.11MB Payment Info Subtotal: Service Hrs Discount CRGC Officer Discount Primary Work Hrs S/P Work Hrs Discount Type Adjusted Subtotal Payment Method * PayPal or Credit Card Check via US Postal Service/Clubhouse Guest Fees Box PayPal or Credit Card payments are charged an additional Processing Fee.A PayPal account is not required to use the PayPal Payment Service. At the PayPal login screen click the Pay with Debit or Credit Card option if you do not have or do not want to use a PayPal account. Processing Fee Total Due: Officer's Total Due: After clicking the Submit button, please wait for the confirmation message to display before leaving the page. If you interrupt the submission, your renewal application may not be processed. Thank you Administrative Information Service Hours Discount Officer Discount Payment Type Processing Fee Year to Year Comparison Fields Submit If you are human, leave this field blank.