The Robert Cuccioli 2013 Fan Club Membership Application

(please print)




State:________________    Zip:____________   Country:______________

Home Phone:______________________________  

Email Address*:________________________________

Birthdate (year not needed)_______________________




Single membership  $20 

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

International membership  $30

New member packages will be mailed within 5-7 business days after receipt of payment.

Please email if any questions

All information provided is kept private and confidential.   

Email and phone numbers will be used for urgent news and quick communication.

Please make all checks payable to GAY DUPRE and mailed to:

The Robert Cuccioli Fan Club

% Gay Dupre

830 Rockbass Road

Suwanee, Georgia  30024