Print this form and mail with the appropriate membership fee to:

Tim Pernes

3401 Cromart Ave

Fort Worth, TX  76133


Name: __________________________________

Address: _________________________________

City, State, Zip: ___________________________

Phone: __________________________________

E-mail: __________________________________

Type of membership:

____Student $5 (K-12)

____Adult $20

____Family $25

If student, School & grade: __________________

If adult, place of employment:________________

Check all that apply:

____ I am interested in scholastic chess

____ I am interested in open chess tournaments

____ I am a school coach or chess club organizer

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