MEMBERSHIP | HSSA

First Name

Last Name

Address (street, city, state, zip)

Occupation

Date of Birth

How long have you been connected to amusement business?

With whom and in what capacity?

I am a citizen of

the United States of America

Canada

Are you a citizen of such country by

Birth

Naturalization

Place of Birth

Date and place where you were naturalized

Do you anticipate any pecuniary benefits by becoming a member of HSSA?

Do you know of any physical ailment or other matter that might cause you to become a burden upon the HSSA?

Give as references at least two members of the HSSA.

First Reference Name

Second Reference Name

Address - first reference

Address - second reference

If the answer is yes, give date when you were so proposed.

Were you (check proper space)

Elected

Rejected

None

If you have been previously elected to membership in the HSSA, state the date and reason for your withdrawl or suspension.

I declare that the info I’ve provided is accurate & complete

Signature of Applicant

Thanks for submitting!

THE ABOVE FORM MUST BE COMPLETELY FILLED OUT AND ALL QUESTIONS ANSWERED.

$5 INSTALLATION FEE AND $25 DUES MUST ACCOMPANY THE APPLICATION TO BE ACCEPTED.

(ONLINE PAYMENTS REQUIRE AN ADDITIONAL 4% PROCESSING FEE)

710 Whittington Avenue, Hot Springs National Park, Arkansas 71901