Gopher Wheelmen			Mail completed form to:			
	Membership Form			Lynn B			
	2008					669 Grand Ave #3A, 
							St. Paul, MN 55105		

	Please print.										Please print.				

Check One					
[ ] Send My Membership Packet Via email 									
[ ] Send My Membership Packet Snail Mail									


Membership Renewal:   _______			DUES:  $20.00		Amount enclosed:  ______			

New Membership:       _______									


NAME:	___________________________		_________________________________				
		(first)			                (last)				
									
RENEWING MEMBERS: ONLY INDICATE ADDRESS CHANGES FROM LAST YEAR								

ADDRESS: ___________________________________________________________									
									
	____________________________________	_____________	  ________________			
		(city)					           (state)	          (zip code)			
									
PHONE: (_____)_____________   (______)_______________			(_____)_____________			
		(home)			      (work)							(cell or mobile)		
									
E-MAIL ADDRESS: _____________________________________________________									
									
Do you hold a current racing or officiating license?  USCF: Yes _______ No________									
									
									  				 NORBA: Yes______ No______				
											
Road category _________ Track category  _________  MTB Level ________ Official ________											
											
Date of Birth: ____________________				Gender:  M ____ F ____							
											
Cycling info - check all that apply:											
											
Racing:  Road _____ Crits ____Time Trials ___ Track ____ MTB ____Cross  ___ Ultra ____											
											
											
All club members are expected to participate in volunteer work each year on behalf of the club.											
											
Please list your volunteer efforts for 2006 including the name of your event promoter/coordinator:											
(Renewing Members Only)											
											
											
									
What events or volunteer areas are you interested in for 2007:									
Ken Woods RR: 					Other: