PCGCC Application

(Print this page, fill it in, and mail to the address below.)

Membership Application for the Phoenix and Consolidated Glass Collectors Club

Name(s): ___________________________

Home Phone (including Area Code) : __________________________
E-mail: __________________________
Address:
___________________________
___________________________
___________________________

Business Name : ___________________________

Business Address : ___________________________

Business Phone: ___________________________

Business Email : ___________________________

Business Website: ___________________________

______ Include me in the membership roster: YES ____ NO ____

How did you hear about the club?:
_____________________________________________________________
_____________________________________________________________

Dues: _____ $25.00 for single; _____ $35.00 for couple
(dues include a subscription to our quarterly newsletter).

Make checks payable to: PCGCC
Mail to:


PCGCC
 Ruth Ann Davis, Treasurer
 P.O. Box 387
 Southington, CT 06489
E-MAIL:ruthann11@cox.net

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