Ocean County Coin Club, Inc.

Name: ____________________________
Home Address: ___________________________ City _____________ State ______ Zip _________
Mailing Address: __________________________ City _____________ State ______ Zip _________
Home Phone: (_____) ___________
Email Address: ______________________
Birthday**: Day ______ Month ______ Year (juniors only) ______
Dues (check one):
- Regular member - $10 ____
- Junior member - $5 ____
- Family member - $15 ____
How did you hear about us? _______________________________
Signature: _________________
Parent Signature (junior members only): _________________
Date: _____/______/____
1st read ____ 2d ______ Approved ____
Please make checks payable to O.C. Coin Club & mail to OCCC - 65-16th St, Toms River, NJ 08753

** Note: Birthday information is required for eligibility in the monthly "Birthday" drawings, which are held at the meetings. Adult members need only provide "Day" and "Month" information. Juniors must also include "Year" information, as junior membership is available to those from 6 to 17 years of age. Members enrolled through a "Family" membership can submit up to two birth dates (per membership) to be included in the "Birthday" drawings.