Application

6th Maine Battery

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Army of the Potomac

1862-1865

APPLICATION FOR MEMBERSHIP

PLEASE PRINT OR TYPE

1.   NAME: …………………………………………………………………  TELEPHONE:………………………………………

                      (LAST)                                        (FIRST)

2.   ADDRESS: ……………………………………………………………………………………………………………………

                               (STREET AND NUMBER)                                                   (CITY)                         (STATE)                         (ZIP)  

3.   DATE of BIRTH: …………………………………………..  4. OCCUPATION:…………………………………………..

5.   EMPLOYED BY: ……………………………………………………………………………………………………………..

                                  (BUSINESS)                                                           (ADDRESS)                                                             (TELEPHONE)

6.   ARE YOU A U.S. CITIZEN?     YES (   )    NO (   )                           MARRIED:     YES (   )   NO (   )

7.   DO YOU HAVE ANY COURT CONVICTIONS?  YES (   )    NO (   ) IF YES, EXPLAIN ON A SEPARATE SHEET

8.   IN WHAT OTHER ORGANIZATIONS DO YOU PRESENTLY HOLD MEMBERSHIP? …………………………………

      ………………………………………………………………………………………………………………………………………

9.   PLEASE PROVIDE TWO PERSONAL REFERENCES (Other than family)

      REFERENCE 1: …………………………………………..   REFERENCE 2:  ……………………………………………..

                                 …………………………………………..                              ………………………………………………

                                 …………………………………………..                              ………………………………………………

10.  WHAT ARE YOUR PARTICULAR INTERESTS IN THIS ORGANIZATION?

       (   )  PARADES

       (   )  BATTLE  REENACTMENTS

       (   )  HISTORY

       (   )  OTHER (Please Indicate) ………………………………………………………………………………………………..

11.  WHAT CATEGORY OF MEMBERSHIP DO YOU PREFER?

       (   )  ACTIVE MEMBERSHIP ($25 ANNUAL DUES – FULL PRIVILIGES AND VOTING RIGHTS)

       (   )  FAMILY MEMBERSHIP ($40 ANNUAL DUES – FULL PRIVILIGES, 16 and over to VOTE ) 

12.  ARE YOU NOW OR HAVE YOU EVER BEEN AFFILIATED WITH AN ORGANIZATION OR MOVEMENT

       DESIGNATED BY THE U.S. ATTORNEY GENERAL AS ADVOCATING THE OVERTHROW OF THE

       GOVERNMENT OF THE UNITED STATES BY FORCE OR VIOLENCE?

       YES  (   )     NO  (   )

I WARRANT THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

SIGNED: ……………………………………………………………………  DATE:……………………………………………..

INSTRUCTIONS FOR APPLICATION:

1.     COMPLETE SECTIONS 1 THROUGH 12.  IF A QUESTION IS NOT APPLICABLE, INDICATE SO.

2.     SUBMIT APPROPRIATE DUES WITH THIS COMPLETE APPLICATION.

3.     MAIL APPLICATION AND DUES TO THE FOLLOWING ADDRESS:

6TH MAINE BATTERY

422 RIVERSIDE DR.

EDDINGTON, ME.  04428

OR YOU MAY DELIVER COMPLETED APPLICATION WITH FEE TO ANY 6TH MAINE BATTERY

OFFICER OR NON-COMMISSIONED OFFICER AT ONE OF OUR FIELD EVENTS.

RELEASE AND WAIVER OF LIABILITY

I understand that the operation of muzzle loading artillery and other activities associated with it, including but not limited to the transporting, loading, and firing of black powder cannon and mortars and the transporting, loading, and firing of other black powder firearms, are inherently dangerous due to the nature of the materials and the processes involved, even so far as to be life threatening.

Irrespective of any instruction I participate in or receive with respect to such operation of muzzle loading artillery and other activities associated with it, including but not limited to the transporting, loading, and firing of black powder cannons and mortars, as well as to the transporting, loading, and firing of other black powder firearms, I agree to assume any inherent risk associated with membership in the 6th Maine Battery, Army of the Potomac, and I further agree to assume all responsibility and hold harmless, the 6th Maine Battery, Army of the Potomac, it’s officers, directors and members of the event, of injury, death, or property damage, whether caused either in whole or in part by my own negligence, or by the negligence of any other participant or observer, including but not limited to the 6th Maine Battery, Army of the Potomac, including its officers, directors, and members.

SIGNED: ……………………………………………………………………………  DATE: ………………………………

WITNESSED: ………………………………………………………………………  DATE: ………………………………

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