Dayton Diode Wiki
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'''Name:''' ___Wesley Hartshorn________________________________________
'''Name:''' ___________________________________________
 
   
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'''Address:''' _____1353 Creighton Ave.____________________________________
'''Address:''' _________________________________________
 
   
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______________Dayton, OH 45420___________________________________
_________________________________________________
 
   
 
_________________________________________________
 
_________________________________________________
   
'''Phone number:''' _________________________
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'''Phone number:''' __937-239-6685_______________________
   
'''Email address:''' ___________________________________
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'''Email address:''' ___wes@physisfilms.com________________________________
   
 
<u>'''Initial each of the following:'''</u>
 
<u>'''Initial each of the following:'''</u>
   
______ '''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 Charter]].'''
   
______ '''I have read and agree to abide by the [[Dayton Diode Membership Agreement|Membership Agreement]].'''
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__wh____ '''I have read and agree to abide by the [[Dayton Diode Membership Agreement|Membership Agreement]].'''
   
______ '''I have signed the [[Limit of Liability Form|Liability Waiver]].'''
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____wh__ '''I have signed the [[Limit of Liability Form|Liability Waiver]].'''
   
   
   
'''Applicant Signature:''' ____________________________________ '''Date:''' ____________
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'''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: ____________


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Consensed on by Dayton Diode membership on Nov 2, 2010.