Date of Application  ________________
Type:    □ Family * (see below)     □ Individual (Check one)
Name: ________________________________  Phone: ___________________________
Address: ______________________________  City: _____________________________
County: ______________________________  State: ____________  Zip: ____________
E-Mail: ______________________________  Date of Birth: ______________________

Are you a member of NRA, NMLA, or other group?                   Y     N
Do you hold a Firearms Identification Card where required?   Y     N
Do you belong to another reenactment group?                           Y     N
If so, what is the name of the group?  _________________________________________

Emergency contact:
Name: _______________________________  Relationship: ______________________
Phone: ______________________________

Category of prime member: (Check one):    □ Man at arms    □ Civilian    □ Sutler    □ Musician

Application Fee:
    Initial:     $5 for Provisional Member (Subject to review in 6 months)
    Renewal:     $5 for Regular Member

PRINT THIS PAGE & SEND THE COMPLETED FORM WITH THE FEE TO:
    Andy Lieb, NJM~HB
    128 White Pine Ct.
    Paramus, N.J. 07652
(Checks made payable to: New Jersey Militia, Heard's Brigade)

My signature indicates my agreement to abide by all the by-laws of the organization as well as the laws of all states and rules and regulations of various umbrella organizations and sponsors of events. I also understand that by becoming a re-enactor I will strive to present the most accurate and complete portrayal of the life and times of the Colonial Militia as I am able to.

Signature: _______________________________  Date: : ______________________
□ New Member □ Renewal (Check one)

*Family Membership: List all family members
For each: Name/Date of Birth/Relationship/Category : Man at Arms/Civ/Sutler/Musician:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List additional family members on separate sheet and attach.