|
 |
Membership Application |
Instructions: Please print this page and send payment to the address below
| Name: | ________________________________________________ |
| Street or Box: | ________________________________________________ |
| City, State & Zipcode | ________________________________________________ |
| Email Address: | ________________________________________________ |
| Phone Number: |
________________________________________________ |
| Date: |
________________________________________________ |
| 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: Elizabeth A. Schwab, Sec.
706 S. Washington Street
Jerseyville, IL 62052 |
| |
