San Fernando Valley Tip Toppers
                                  Application

                         * = Required information

I wish to:  Become a Member: ____    Renew My Membership: ____

            Receive the newsletter only: ____
Note: Please do not send payment for dues until you have been voted in.

*Name: _____________________________________________

Nickname: __________________________________________

*Address: __________________________________________

*City: _____________________________________________

*State: _________         *Zipcode: ________________

*Home Phone: _______________________________________

Work Phone: ________________________________________

Occupation: ________________________________________

*Height: ______ ft. ______in.

*Sex: Male: ______  Female: ______

*Birthday: Month: ______  Day: _______

E-mail address: ________________________________________________________

Interests: _____________________________________________________________

           _____________________________________________________________

Hobbies: _______________________________________________________________

           _____________________________________________________________

Qualities you seek in others: __________________________________________

           _____________________________________________________________

Are you a member of another TCI affiliated club?     Yes: ___    No: ___

If Yes: What Club: _____________________________________________________

*How did you find out about the San Fernando Valley Tip Toppers? _______

           _____________________________________________________________

           _____________________________________________________________

What club activities would you like to participate in?

Social: ___     Administrative: ___     Newsletter: ___

Other: __________________________________________________________________

Periodically, the club publishes a roster of all members, including their
address and phone numbers. That information, as it pertains to you, will
be automatically included in the next edition unless you specifically
request that all or some be deleted.

Please do NOT publish my:

Address: ___     Phone Number: ___     E-mail address: ___

By signing below, you certify that all statements made in this application
are true and agree and understand that any misstatements of material facts
herein will cause forfeiture on your part of the right to become a member
of the San Fernando Valley Tip Toppers. You also understand that the above
information is to be kept strictly confidential and is not a commitment in
any way, shape or form other than to become a Regular Member upon satisfaction
of the membership requirements. You further acknowledge that your address and
phone number will be published (except as noted above), and you will hold the
Club free and harmless for any and all consequences of that publication
(membership information will NOT be sold).

* I accept these terms: Yes: ___  No: ___
s

Sigend: __________________________________________   Date: __________________

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Send Application to:

                     Membership Chairperson
                     San Fernando Valley Tip Toppers
                     P. O. Box 2756
                     Van Nuys, CA 91404-2756