Membership Application For The Casino Chip & Gaming Token Collectors Club
(Print out the application & then mail the filled out application with payment to the address at the bottom of this page)

MEMBERSHIP APPLICATION CASINO CHIP AND GAMING TOKEN COLLECTORS CLUB

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/_/ Please do NOT publish my name and address.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&GTCC to:

Sponsored by: John Haines - R-3792

Ralph Myers
CC&GTCC Membership Officer
P.O. Box 35769
Las Vegas, Nevada 89133-5769