MembershipType of Membership: Single_____ Family_____
Date of this application: _______________20____
Please fill out entire application: Enclose with one years' dues ($25.00 for single
membership or $50.00 for a family membership). Make check payable to Cooper's Battery B.
If family membership, please list spouse and any dependents, in same household as applicant,
on reverse. Include Dates of Birth , and signatures. If membership is not approved, you will
receive a full refund of dues. Cooper's Battery B is a section 501(c)3 nonprofit corporation.
Name:______________________________ Date of birth:________________
Address:_______________ City:________________ State:___ Zip:_________
Phone:_______________ Cell:_______________ Email-________________
Employed By:_________________________ Employer's Phone:____________
Have YOU (or Spouse/dependents if applicable) ever been convicted of a crime?
Yes___ No___ If yes, explain for anyone applicable.___________________
Were you referred by someone? Yes___ No___ If yes, Name:_______________
Are you a member of another Civil War Reenactment Group? Yes___ No___
If yes, what group? ________________________________________________
Reason for wanting to join this organization:_____________________________
Name:____________ Address_________________________ Phone:________
If under 18 years of age you MUST have a parent or guardian as an active
member of Cooper's Battery.
Parent/Guardian's Signature: ________________________________________
Providing any false information will lead to immediate dismissal from Cooper's Battery.
In signing this application, you agree to absolve and release Cooper's Battery B of any
and all liabilities for personal injuries, theft, or accidents of any kind.
Return to: Scott Debo, 144 Race Street, Sunbury PA, 17801
Questions call: Scott 570-286-8997 OR Dennis Dewalt 570-648-3001