Simply print out this form fill in the information and Mail it to the following address:

Lowell Bennette Fan Club
103 Kale Ave.
Sterling, VA 20164

Address:__________________________

City:____________________ State: _______ Zip:_________

Daytime Phone Number:______________

T-Shirt Size:________________________

E-mail:____________________________

Please include a check or money order made payable to Lowell Bennett Fan Club.

Single Membership is $18.00
Family Membership is $25.00

Allow 2-4 weeks for shipment of club kit.