|
 |
Membership Application |
Instructions: Please print this page and send payment to the address below
| Name: | ________________________________________________ |
| Street or Box: | ________________________________________________ |
| City, State & Zipcode | ________________________________________________ |
| Email Address: | ________________________________________________ |
| Telephone: |
________________________________________________ |
| Date: |
________________________________________________ |
| Please circle membership you desire - |
| |
| Annual Individual Membership dues are $10.00 |
| |
| Annual Family Membership dues are $15.00 (Please include name of spouse and any children under age 18, still living at home.) |
| |
| Annual Corporate Membership dues are $50.00 |
| |
Lifetime Individual Membership dues are $150.00
Lifetime Family Membership dues are $200.00 |
| |
| Make check payable to: Tri-County Antique Club |
| |
Mail to: Tom Bechtold, Treasurer
12894 Fessler Road
Dow, IL 62022 |
| |
