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Qualification Questionnaire

THANK YOU for your interest in the
Rocky Mountain Sportsmen Association.

Fill in the Information below and click the submit button. Mail your payment and Waiver/Release form to :
Rocky Mountain Sportsmen Association
7067 South Pierce Court
Littleton, CO 80128
We will e-mail you a confirmation as soon as your check has been received. You may also print out this page,
fill it out and mail it along with your payment.

Name or Corporation:	Spouse/Corp designate name:
Mailing Address:	City/State:	Zip:
Permanent Address:	City/State:	Zip:
Phone w/area code:	Business Phone w/area code:
E-mail:

List names and birthdays of dependents eligible for cards.
(Dependents must live in same household)

Dependent name: Birthdate: Relation:

Dependent name: Birthdate: Relation:

Dependent name: Birthdate: Relation:

Dependent name: Birthdate: Relation:

Dependent name: Birthdate: Relation:

Dependent name: Birthdate: Relation:

Occupation: Employer:

Approx. Annual Household Income: (check one)
$15,000-$19,999 $20,000-$29,999 $30,000-$39,999 $40,000 plus

How long have you lived in the state? Moved from:

Favorite outdoor recreation activity:

Which have you hunted/fished or would like to in the future?

Elk	Mule Deer	Whitetail	Bear	Bighorn Sheep	Dall Sheep
Antelope	Caribou	Moose	Wild Boar	Javelina	Mtn. Lion
Exotic Game	Pheasant	Quail	Dove	Grouse	Chukar
Turkey	Ducks	Geese	Rabbit	Squirrel	Bobcat
Varmit	Trout	Salmon	Bass	Muskie	N. Pike
Pan Fish	Deep Sea Fish	Walleye Pike

List your favorite type and experience in each of the following catagories:

Hunting:	Years:
Fishing:	Years:
Camping:	Years:

SCREENING DATA .................................................................................
Have you ever had a hunting accident? Yes No
Have you ever had a state game or fish violation in the past five years? Yes No

If you answered yes to any of the above questions, please explain:

How well do you know this state's hunting and fishing regulation? Excellent Good Fair
Would you object to RMSA checking the state fish & game records? Yes No
Have you ever been convicted of a felony? Yes No
How concerned are you with conservation and ecology? Very Somewhat Not concerned

What are you finding outdoors that distresses you?
(Explain your suggestions for a solution if you would like)

Type of property you would use the most: (Pick top 3)
Big Game Waterfowl Fishing Upland General Recreation

REFERENCES ............................................................................................

Because members are carefully screened, we will need the names of four personal references
(IN THIS AREA) who would know something about your outdoor interests, attitudes and conduct.

Name:	Address:
City:	State:	Zip:
Home Phone:	Business Phone:	E-mail:

Name:	Address:
City:	State:	Zip:
Home Phone:	Business Phone:	E-mail:

Name:	Address:
City:	State:	Zip:
Home Phone:	Business Phone:	E-mail:

Name:	Address:
City:	State:	Zip:
Home Phone:	Business Phone:	E-mail:

CODE OF ETHICS.................................................................................

BASIC FACTS......................................................................................

The preceeding information is true and correct to the best of my knowledge. I understand the Rocky Mountain Sportsmen Association is not obligated to accept me has a member. Should I be accepted as a member, I agree to respect the properties and obey the rules established by the RMSA for their use.

Applicants Signature _________________________________ Date _____________
I understand that if this form is submitted over the internet my signature on my check and Waiver/Release form (Both required for membership) will constitute agreement to the above information. Agree Disagree

Name as it should appear on the certificate:

RMSA PROPERTIES
Chapman Ranch Unit #581 • Aspen Leaf Ranch Unit #521 • Hotchkiss Ranch Unit #521
Jacobs Ranch Unit #521

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