(Print Out This Form)
Application for Membership
Last Name: _____________________ First Name: __________________
Spouse: ______________________________________________
Business Name: _______________________________________
Mailing Address: _____________________________________
City:
Telephone (Home): ______________(Work): ______________
Fax Number: __________________________________________
E-Mail: ______________________________________________
______ When available, I would like to receive the Newsletter by e-mail.
The above information will appear in the Pickard Collectors' Club Annual Membership Directory unless otherwise marked.
______ Please do not include my address and telephone number in the directory.
_______ New Membership
_______ Renewal - Membership Number _________
Annual Membership Fees:
Check enclosed for $30 Single Membership _______= ______
Check enclosed for $40 Family Membership _______= _______
Total Enclosed ________