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