Membership Form
Ohio Horseman’s Council, Inc.
Membership Application For Year 20__
(Membership is from January 1 to December 31)
( ) New ( ) Renewal Member Since ______________
Please print clearly or type
Name: _________________________________Age: _______Phone: __________________________________
Spouse: ________________________________ Age: _______Cell Phone:_______________________________
Address: ___________________________________________________________________________________
City: ______________________State: ____Zip: ________ E-Mail: __________________@______________
Primary Chapter ___________________________________ At-Large: At-Large members Mail To:
The Corral and State Quarterly are included in your membership fee. Anne Lindimore, State Treasurer
I do not want to receive the Corral. I do not want to receive the State Quarterly. 3680 E. St. Rt. 60 N.EMcConnelsville, OH 43756
Note: Some OHC chapters charge an additional fee to cover costs of chapter newsletters, etc. You may be notified of same by that chapter.
OHC Basic Membership
(Without Equine Excess Liability Insurance)
OHC Plus Membership
(With Equine Excess Liability Insurance)Type
Membership
Fee
Chapter
Charge Total
Type
Membership
Fee
Chapter
Charge Insurance Total
Single $15.00 $ $ Single $15.00 $ $19.00 $
Family $22.50 $ $ Family $22.50 $ $38.00 $
Sen. Cit.* $ 8.75/ea. $ $
Student** $12.00 $ $
Senior
Cit.*
$ 8.75/ea. $ $19.00/ea $
* Age 62+ as of January 1
**Under Age 18 as of January 1
*Age 62+ as of January 1
Associate Membership
No. of Members
Membership
Fee
Association President/Chairperson:
$25.00
Address (If different from above):
If family membership, list names and ages of children under 18 (this is needed for insurance purposes).
1. _______________ ______ 2._______________________ 3._______________________ 4._______________________5. ___________________
SIGNATURE (required): ___________________________________________________________Date:________________________
(Parent/Legal Guardian must sign for student under age 18)
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(FOR CHAPTER USE ONLY)
Make checks payable to: _________________ County OHC Dual Membership Fees: Family: $ , Single: $ , Senior Citizen: $
Mail To: State Dues & Insurance: $_________
County Chapter Fees: $_________
Dual Membership Fee: $_________
Membership Card Issued By: ___________________________ Date: ______________________ Total Fees: $_________
Member’s Cell Phone No: ( )_______________________
Secondary Member’s Primary County:____________________
(You may not become a secondary member unless you have membership in a primary county.) www.ohiohorsemanscouncil.com
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