The Robert Cuccioli Internationa

The Robert Cuccioli International Fan Club

2011 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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2012 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.