The Robert Cuccioli International Fan Club

2013  Renewal Form

 

Single membership         $20

Family membership        $20 first member plus $10 for all additional members living in same house. ($30)

International membership    $30

 

 

Name:____________________________________________________________________

 

Address:__________________________________________________________________

 

City:_________________________________State______________   Zip ______________

 

Country:___________________        Phone #_____________________________________

 

Email Address:_______________________________  Birthdate:_____________________

 

Additional Household Members:

 

Name:____________________________________________________________________

 

Email: ____________________________________________________________________

 

Comments:________________________________________________________________

 

_________________________________________________________________________

 

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 2013 Calendar $25/each - Quantity _________________________

Checks for membership fees and calendar can be combined.  Please make all checks payable to Gay Dupre.

All Membership renewals should be sent to:

The Robert Cuccioli International Fan  Club

% Gay Dupre

830 Rockbass Road

Suwanee, Georgia 30024

 

Checks should be made payable to:   Gay Dupre

Please contact me if you have any questions regarding your membership.

770-888-9448                    Gay@RobertCuccioli.com