BLUE RIDGE INSULATOR CLUB

MEMBERSHIP APPLICATION

Name: _________________________________________

Mailing Address: ________________________________

City/State: _____________________ Zip: ____________

Telephone: ______________ Email: _________________

Please indicate membership class:

* Family $15.00

*Individual $10.00

*Junior (16 and under) $4.00

List other family members (Family membership only):

1. _____________________ 2. _____________________
2. _____________________ 4. _____________________

Are you a member of the NIA? If yes #_______________

What are your collecting specialties? (Color, Embossing, Manufactures…..)

Would you be willing to host a club meeting? YES/NO

Would you be willing to show your collection to others? YES/NO

Do you wish your Name/Address/Email to be published in newsletters

or made available to other collectors? YES/NO

Amount enclosed: ________ Signature: ________________

Make Checks payable to the Blue Ridge Insulator Club and return to:

Gill Pollard

250 Sunnybrook Lane

Boones Mill, VA 24065