WHEELING COIN CLUB
MEMBERSHIP APPLICATION
NAME: _______________________________________________ DOB: ____________
VERIFICATION: _________________________________________________________
ADDRESS: _____________________________________________________________
CITY & STATE: ________________________________________ ZIP: _____________
PHONE: ___________________________ EMAIL: _____________________________
[ ] REGULAR MEMBERSHIP (18 YEARS OR OLDER) $12.00
[ ] JUNIOR MEMBERSHIP (17 YEARS OR UNDER) $4.00
APPLICANT SIGNATURE: _______________________________________________
SPONSOR SIGNATURE: ________________________________________________
SPONSOR NUMBER: __________________
DATE ____/____/____ NUMBER ASSIGNED __________ EXPIRES ____/____/____
PAID IN FULL ON THE ABOVE DATE WITH CHECK #__________ OR CASH