City, State, Zip:________________________________   Email Address:______________________

Home Phone:_____________ Work Phone:______________ AAGP Membership Number:________

In Case of Emergency Notify:_________________________ Relationship To You:_______________

Address:________________________________________ Phone Number:____________________

I wish to become a member of the following Chapter of the AAGP: (Circle One)

1. Phoenix     2. Tucson     3. Prescott     4. Quartzsite/Yuma     5. Miami/Globe/Superior.
*Please note that some of the above chapters are still in the formative stage. Positions are open for Chapter Chairman and Claims Inspector in some of the above chapters. If interested, please indicate position and chapter here:___________________________.

Type of equipment owned:(circle all that apply)  Pan  Dredge  High-Banker  Rocker Box  Sluice  Dry-Washer  Metal Detector(Name & Mfgr.)____________________________________________________.

Other types of prospecting/mining equipment:_____________________________________________.

Vehicle to be used while on the claims:

Year ___________  Make ______________  Model _________________  St. & Lic. # _________________.

I would like to see the following events made available to me as a member and if they are scheduled, I will participate and help encourage others to participate as well:
1._______________________ 2._______________________ 3._______________________ 4._______________________ 5._______________________ 6._______________________.

I understand that AAGP membership is on a purely voluntary basis. I hereby agree to follow all rules and regulations as set forth in the AAGP Rules and Regulations and as set by the U.S. Department of the Interior, Forest Service, Bureau of Land Management(BLM), and the Arizona Department of Fish and Game. I understand that I will receive no remuneration or consideration for my membership to the local AAGP Chapter other than the knowledge that I have served my fellow prospectors and made the recreational prospecting industry better through my efforts. It is further understood that I accept full responsibility for the actions of myself, those of my family and/or guests and any others who may also be on the claims and that I have no recourse in the event of injury or sickness on the claims and that I will hold blameless and harmless all AAGP members, AAGP officers, the AAGP claims owner(s) and their agents and representatives.

Signed: _________________________________________ Date: ____________

Please fill out and mail along with your Membership Application and payment to:

Arizona Association of Gold Prospectors, Inc.
P.O. Box 35281
Phoenix, AZ 85069-5281
(623) 934-6882