DEEP SOUTH CHIP COLLECTORS' CLUB
MEMBERSHIP APPLICATION

Date:__/___/____
Member Number: ________ (Office Use)

Name_________________________ ___________ ____
(Last) (First) (MI)

Address____________________________________________
(Street)

City__________________________ State__________ Zip_______

Country__________________

Telephone (H)_____/_____/__________ Work_____/____/__________

E-mail address_____________________________
Address will NOT be sold or distributed outside the Club without the express permission of the member

My collection interests are: Chips__ Tokens__ Silver Strikes__
Other________________________

You may publish my name and address:______
Please do NOT publish my name and address:_____

I have enclosed my annual dues for:

One year first time member: $15 U.S._____

One year renewal: $10 U.S._____

Life Membership: $150 U.S._____

Annual dues will be due and payable by January 31st of each year.
Please make checks payable to: Deep South Chip Collectors Club.

Mail to:

Deep South Chip Collectors

c/o Top Newby

10676 Sun Up Court

Milton, FL 32583