Membership Application    

Please print this form and fill it out. Mail it with your fees to: Heart of Ohio Trail Inc., P. O. Box 702, Centerburg, Ohio 43011

Today's Date:___/___/___         
< Application Type:  _____Associate (<18 years old, $5)     _____Voting (18 years and older, $10)>

Name: (Last, First M.I) ________________________________________________________
Date of Birth  mm_____/dd_____/yy_____

Email: _________________________________________  
Phone: (home)________________/ (busines)_______________

Anticipated Uses (Please check all that apply):    _____Bicycling     ____Bird watching    
_____Hiking/walking   _____Horseback riding    _____Rollerblading  
_____Other (please specify):________________________________

Volunteer Interest (Please check all that apply):   ____ Construction/maintenance   _____Fund raising  
_____Publicity_____Special Projects  
_____Other (Please specify)__________________________________________________

Dues received by: ______________________   Amount:_____________  Date:________________

Thank you!

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