Instructions: Please print this page and send payment to the address below

Street or Box:________________________________________________
City, State & Zip Code:________________________________________________
Email Address:________________________________________________
Telephone: ________________________________________________
Date: ________________________________________________

Please circle membership you desire -
Annual Individual Membership dues are $10.00
Annual Family Membership dues are $15.00 (Please include name of spouse and any children under age 18, still living at home.)
Annual Corporate Membership dues are $50.00
Lifetime Individual Membership dues are $150.00
Lifetime Family Membership dues are $200.00
Make check payable to: Tri-County Antique Club
Mail to: Tom Bechtold, Treasurer
27622 N. Davenport Drive
              Godfrey, IL 62035