Deer Valley Collectors

DEER VALLEY COLLECTORS

Membership Application Fee $20.00 / Year

Date Joined - Day ______ Month _______ Year_________

Name (Please Print) ______________________________________

Name of Spouse __________________________________________

Occupation _____________________________________________

Phone ___________ ___________ _______________

Address ________________________________________________

City __________________________________________________

State _______________________________ ZIP _____________

Email address ___________________________________________

Amount Paid ________ __________________

Date paid __________________

Send your $20.00 to:

Les Shollenberger

18120217th St.

Davenport, Iowa 52804

563-285-4690

MAKE CHECKS PAYABLE TO:

DEER VALLEY COLLECTORS