APPLICATION FOR MEMBERSHIP - Complete ON-LINE, then Print & Mail with Dues to:

AMERICAN HARNESS DRIVERS CLUB, INC.
84 CHERRY TREE FARM ROAD
MIDDLETOWN, NJ 07748
(732) 671-4632 Fax (732) 706-1557
Dues for 2008 - $200.00 - Make Checks Payable to: "AHDC"

Please Choose One: NewRenewal
(New Members Please List THREE trainers as references on the back of the form.)
Name: Date of Birth:
Address:   (MM/DD/YY)
     
City:    
State: Zip:
Home Phone: Work Phone:
Best Time/Call: Fax Number:
E-Mail Address:    
USTA Membership Number:    
*New Jersey Licence Number: Driver Code:
  *AHDC DRIVERS MUST BE LICENSED BY NJRC !!    
Has your NJ License ever been Suspended or Revoked ? Yes No
If Yes, Please Provide Details on a Separate Sheet of Paper.
Do You Own Race Horses? If Yes, Please List.
Trainer: Telephone:
Horse Name Age Gait Conditions Now Racing
The information provided in this Application for Membership is true and correct. If accepted, any misstatement or omission of fact on this Application may result in dismissal from the club.
Date: Signature:_______________________________________