Mike Gardner Fan Club Membership Form

< Mike Gardner Fan Club Membership Form

Mike Gardner #45 Fan Club Membership Form
(Good for One Year from Date Joined)

*Required Fields = Fill in required fields, print and mail membership form to address at bottom**
First Name:	*
Last Name:	*
Mailing Address:	*
City:	*
State:	* Zip: *
Phone:
Email:
Birthdate:	If you do not include your birthdate, you will not be entered into any fan club drawings.

T-Shirt Size:	Adult Small Adult Medium Adult Large Adult X-Large

Name on card:
	How would you like name on card? Only one name per fan club membership.
Mike Gardner #45 Fan Club 7645 Lake Bluff 19.4 Road Gladstone, MI 49837 Enclose $19.95 for Fan Club Membership - Includes Shipping & Handling Canada Residence Enclose $24.95 Allow approximately 1-2 weeks for delivery Make Checks Payable to: Mike Gardner