Print this form and mail with the appropriate membership fee to

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:

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