The Robert Cuccioli Internationa

The Robert Cuccioli International Fan Club

2010 Renewal Form

Single membership $20

Family membership $20 first member - $10 all additional members

International membershp $30

Name:____________________________________________________________________

Address:__________________________________________________________________

City:_________________________________State______________ Zip ______________

Country:___________________ Phone #_____________________________________

Email Address:_______________________________ Birthdate:_____________________

Additional Household Members:

Name:____________________________________________________________________

Email: ____________________________________________________________________

Comments:________________________________________________________________

_________________________________________________________________________

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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.