AIR CAPITAL CARNIVAL GLASS CLUB

Membership  Application or Renewal


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Please Print Clearly



__________________________________________________________________

                    Last Name                         First Name                              Additional person


__________________________________________________________________

                    Address                                           City & State                                     Zip Code

                

__________________________________________________________________

                      E-Mail Address                                                       Phone Number


               

 ANNUAL MEMBERSHIP (Household)

Due in October of each year


               Printed: $20.00,  Canada $22.50,   Other $25.00         _________

                                               

Email:     PDF format    $20.00                          _________




Make funds payable to

Air Capital Carnival Glass Club




Print and send application and payment to:


Randy G. Thach, Secretary

39 Osprey Dr

Rockport, TX  78382


For More information contact Randy at:

                                (316) 722-5837  rgthach@twc.com