Membership Renewal Form

Membership dues are for a full calendar year, Jan. 1 – Dec. 31.
Complete this form to renew your membership in the Prince Edward Rod & Gun Club.

Prince Edward Rod & Gun Club

P.O. Box 22003, Picton, ON K0K 0A0

www.pergc.com | 613-480-5366

Personal Information

First Name *

Last Name *

Street Address *

City *

Province *

Postal Code *

Phone / Cell Number *

Email *

Licensing & Status

PAL # *

PAL Expiry Date *

PAL Status *

Other Club Affiliations?

CSSA # *

CSSA Expiry Date *

Your CSSA Membership # will also be your PERGC membership #.

Only paid-up members with a valid CSSA membership are eligible to use facilities and ranges.

Members must renew their own CSSA membership directly through CSSA, either on the CSSA website, by phone at 1-888-873-4339 or 905-720-3142, or by email at info@cssa-cila.org.

Restricted applicants must complete Club Level Handgun Training before using handgun ranges without the presence of a Club Level Instructor.

Membership Type

Select Membership *

Family membership includes spouse and family under 18 years of age and attending school.

Please list each family member separately. CSSA information is required for listed family members. PAL / Minor Licence number and expiry date are optional where they do not apply.

Family Member 1 *

First Name *

Last Name *

CSSA # *

CSSA Expiry Date *

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status *

Family Member 2

First Name *

Last Name *

CSSA # *

CSSA Expiry Date

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status

Family Member 3

First Name *

Last Name *

CSSA # *

CSSA Expiry Date

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status

Family Member 4

First Name *

Last Name *

CSSA # *

CSSA Expiry Date

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status

Family Member 5

First Name *

Last Name *

CSSA # *

CSSA Expiry Date

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status

Family Member 6

First Name *

Last Name *

CSSA # *

CSSA Expiry Date

PAL / Minor Licence #

PAL / Licence Expiry

PAL / Licence Status

Club Communication & Participation

Emails regarding club activities and updates will be sent to the email address supplied on this form.
The Club Executive will be copied on all emails.

Are you willing to be contacted by the club for work events or maintenance required at the club? *

Payment & Submission Instructions

Membership dues: $200.00 for the full calendar year.
Your renewal is not complete until payment is received.

Payment reminder: Membership dues are paid separately from this renewal form.
Complete and submit your renewal form online, then make payment using one of the methods below.

Payment by E-transfer (preferred):

E-transfer $200.00 to treasurer@pergc.com.
Please include your full name in the message field so the payment can be matched to your renewal.

Payment by Cheque:

Make the cheque payable to Prince Edward Rod & Gun Club and mail it to:

Prince Edward Rod & Gun Club

P.O. Box 22003

Picton, ON K0K 0A0

Important: Renewals are not guaranteed if received late. All renewals are subject to review by the executive.

Agreement & Signature

I hereby apply for renewal of my membership in the Prince Edward Rod & Gun Club.
I agree to follow all rules and regulations as set out in the Prince Edward Rod & Gun Club Rules & Bylaws, and I will obey all range rules.

I have read and agree to the Prince Edward Rod & Gun Club Rules & Bylaws and all range rules. *

Signature — type your full name *

Date *

Optional — Print or Save a Copy for Your Records

If you would like a copy of your completed renewal for your records, use the button below before submitting the form.

Membership Renewal Summary

Member Information

Name:

Email:

Phone:

Address:

Membership Type:

Willing to be contacted for work events or maintenance:

Licensing & CSSA Status

PAL #:

Agreement accepted:

I confirm that the information submitted in my online PERGC Membership Renewal form is accurate.
I agree to follow the Prince Edward Rod & Gun Club Rules & Bylaws and all range rules.

Typed Signature:

Date: