The Richard Burgi Fan Club

Membership Registration Form


This is a (tick one):  _____ New Membership    _____  Renewal for Member # ___________________

Name: ______________________________________________________________________________

Street Address:_______________________________________________________________________

City/State/Zip:________________________________________________________________________

Country:_____________________________________________________________________________

Phone: ______________________________________________________________________________

Email:_______________________________________________________________________________

How did you learn of the RBFC?  ________________________________________________________

____________________________________________________________________________________

Dues (Check or Money Order): $20 (US): $25 (Canada): $30 (International): ____________________

Dues (PayPal): $22.00 (US): $27.00 (Canada): $32.00 (International):___________________________

Do you want your name included in the membership directory? (This will be distributed only to RBFC members.)

Yes: ____ No:____

Is this a Gift Certificate Membership? Yes:____ No:____

Your name? _____________________________________________

Make check or money order, in US Dollars ($US), payable to Kathleen Cole.

PayPal transactions, payable in US Dollars, should be registered through the PayPal website at http://www.paypal.com and should be credited to wbkat852@aol.com.

Mail to:
RBFC
c/o Kathleen Cole
11155 Aqua Vista St., #302
Studio City, CA 91602-3700
USA

Latest revision: 04 May 2011