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I, __________________________ ask to be admitted as member of the Quebec Practical Shooting Association (QPSA). As such I am committing myself to follow the principles of Practical Shooting that are listed in the rulebook and the rules of the QPSA. I understand that if I am accepted as a member, my IPSC card remains the property of the Section. I understand and accept that my membership may be suspended or revoked at any time according to the rules of the QPSA. In the case where my membership should be suspended or revoked, I agree to give my IPSC Membership card to one of the Section's directors.

Date: _______________________ Signature: ________________________________________

New Member       Renewal 

Family Name: ______________________________Given Name: _________________________

Address: ______________________________________________________________________

City: _____________________________________ Prov: _______________________________

Country: __________________________________Postal Code: _________________________

E-Mail Address: ________________________________________________________________

Tel (Home): _______________________________(Office): _____________________________

Black Badge No: ____________________________Offical(RO,CRO):_____________________

Club: _____________________________________________________________________________ 

Membership Fees:  $50.00 ($55.00 after January 31, 2001)

Rule Book No.13:   $5.00

Total Included:  

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Are you a member of Federation Quebecoise de Tir? Yes  No 

Walter Pereyma - ATPQ

251 Lacoste St.

Ste. Dorothee, Quebec H7X 3K2