JEFFERSON STATE INSULATOR CLUB MEMBERSHIP APPLICATION

Please indicate one membership class:

  • Individual $5.00

  • Family $5.00

  • Junior (16 years old or under) $5.00

    • Name:___________________________________________ Member # (if renewal)_____

    Address:________________________________________________________________

    City:___________________________________________________________________

    State:________________________________________ Zip Code:__________________

    Telephone:____________________________________

    E-Mail Address:__________________________________________________________

  • Do you wish your Name/Address/Email to be published in newsletters or made available to other collectors?

    • List any additional family members:

    ___________________________________________________________

    ___________________________________________________________

    ___________________________________________________________

    Signature:_____________________________________________ Date:_____________

    Amount Enclosed: $_______________

    Make checks payable to Jefferson State Insulator Club, and send to:

    Scott Morrell
    5508 Pioneer Rd.
    Medford, OR 97501
    (541)608-1043