< 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

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