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| + | '''Name:''' ___Wesley Hartshorn________________________________________ |
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| − | '''Name:''' ___________________________________________ |
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| + | '''Address:''' _____1353 Creighton Ave.____________________________________ |
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| − | '''Address:''' _________________________________________ |
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| + | ______________Dayton, OH 45420___________________________________ |
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| − | _________________________________________________ |
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_________________________________________________ |
_________________________________________________ |
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| − | '''Phone number:''' |
+ | '''Phone number:''' __937-239-6685_______________________ |
| − | '''Email address:''' |
+ | '''Email address:''' ___wes@physisfilms.com________________________________ |
<u>'''Initial each of the following:'''</u> |
<u>'''Initial each of the following:'''</u> |
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| − | + | _wh_____ '''I have read and agree to abide by the [[Dayton Diode Charter]].''' |
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| − | + | __wh____ '''I have read and agree to abide by the [[Dayton Diode Membership Agreement|Membership Agreement]].''' |
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| − | + | ____wh__ '''I have signed the [[Limit of Liability Form|Liability Waiver]].''' |
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| − | '''Applicant Signature:''' |
+ | '''Applicant Signature:''' ___Wesley Hartshorn_________________________________ '''Date:''' _8/11/2014___________ |
Revision as of 03:13, 12 August 2014
Name: ___Wesley Hartshorn________________________________________
Address: _____1353 Creighton Ave.____________________________________
______________Dayton, OH 45420___________________________________
_________________________________________________
Phone number: __937-239-6685_______________________
Email address: ___wes@physisfilms.com________________________________
Initial each of the following:
_wh_____ I have read and agree to abide by the Dayton Diode Charter.
__wh____ I have read and agree to abide by the Membership Agreement.
____wh__ I have signed the Liability Waiver.
Applicant Signature: ___Wesley Hartshorn_________________________________ Date: _8/11/2014___________
Officer Signature: _______________________________________ Date: ____________
Licensed under Attribution-Noncommercial-Share Alike 3.0 Unported based on the Hive 13 Membership Application
Consensed on by Dayton Diode membership on Nov 2, 2010.