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.