MEMBERSHIP APPLICATION

Q. H. R. A. I. M E M B E R S H I P A P P L I C A T I O N

YEAR____________ (JAN. 1 THRU DEC. 31)

NAME_________________________________________

ADDRESS______________________________________

CITY_________________________________________

ST_____ ZIPCODE________________

TELEPHONE: (DAYS)____________________(NIGHTS)______________

FAX___________________e-mail_______________________________

Are you: OWNER___ BREEDER___TRAINER___JOCKEY___

OTHER AFFILIATION WITH HORSE INDUSTRY?_____________________

HOW MANY HORSES DO YOU OWN________________

Please complete this form and mail it and your check or money
order for $25 (U.S. funds) to:

Q. H. R. A. I. Inc.
c/o TERESA GROSS
P.O. BOX 307
LEBANON, IN 46052

Office Use: Postmark________ Computer_______ Card_______

Check No.________Cash______Other_______