NAME:_______________________________________________
ADDRESS:____________________________________________
CITY:_________________________________________________
STATE:___ ZIP:___________(COUNTRY):__________________
PHONE:___________________________
E-MAIL ADDRESS:_____________________________________
My collecting interests are:
(_) Chips (_) Tokens
(_) U.S. (_) Foreign
For the club directory, please publish my:
(_) Name and address
(_) Phone number
(_) Please do NOT publish my name and address.
I HAVE ENCLOSED MY ANNUAL DUES FOR:
(_) One year ($30 U.S.) (bulk mailing)
(_) One year with first class mailing ($44 U.S.)
(_) Associate Membership ($5 U.S.)
(_) Foreign (non-U.S. mailing address) ($55 U.S. - payable by postal money order
or U.S. currency)
Dues will be renewable in the same quarter in which your application is
processed. Check your address label for membership expiration date.
Mail this completed form with your check, payable to CC>CC to: