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Please do NOT publish my name and address:_______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