CZECHOSLOVAKIAN COLLECTORS ASSOCIATION
Membership Form Year 3/1/15 – 2/28/16
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Membership Levels
(Please check one)
_____Individual……….$40
_____Two-Person…….$60
(same address)
_____Institutional…….$55
Donation Levels
(Optional – please indicate amount)
_______Friend…...$10 - $99
_______Patron….$100 - $199
_______Silver…...$200 - $299
_______Gold….…$300 - $399
_______Platinum…..$400+
Sponsorships
(Optional – please indicate amount)
Newsletter...…$__________
Publicity….…..$__________
Website……....$__________
Convention…..$__________
Donations to CCA are accepted on an unrestricted basis. Sponsorship contributions are deposited into the specific fund and
expenditures from the fund must be approved by a majority of the CCA Board.
Please complete this form and mail it with your check or money order payable to CCA to:
David Fein, CCA Membership
810 – 11th Street #201
Miami Beach, FL 33139-4834
Name(s)_______________________________________________________________________________
Address_______________________________________________________________________________
City___________________________________________________State_________Zip________________
Email_______________________________________________Phone_____________________________
Collecting Interests_____________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please check all that apply for publication in the annual CCA Membership Directory.
I am a ___Collector ___Dealer ___Author
Other (please explain)______________________________________
I would like the following published in the annual CCA Membership Directory (Please circle Y or N):
Collecting Interests: Y N
Address: Y N
Phone Number: Y N
E-Mail: Y N
Thank you for your support of the Czechoslovakian Collectors Association.