*Name of Club: 
*Address: 
Address #2:  
*City: 
*State:       *Zip Code:      *Phone: 
*Country: 

Club's President: 
Address: 
City: 
State:       Zip Code:     Phone: 
E-mail address:    


Mail periodicals & correspondence to: 
Address: 
City: 
State:          Zip Code:     Phone: 
E-mail address:    

*Meeting Location: 
*Day:     *Time: 

Newsletter Name: 
Editor: 
Address: 
City: 
State:          Zip Code:     Phone: 
E-mail address:    

Club Show Date: 
Club Show Place: 

*Type of membership offered:  (Individual, Family, Combination)

*What is the Club's total Members?    
(Club must have at least ten members, meet at least quarterly, have open minutes and a treasurer's report
and be a not-for-profit organization.)

*Name of Person Submitting Form: 
*Title: 
E-mail Address:    

Club Website: 

*Fields marked with an asterisk are required fields. However, please fill the form as completely as possible.

Payment options through Paypal are available after form has been submitted.
You will be redirected there upon processing the form.

REMEMBER: Your membership to the Federation of Historical Bottle Collectors,
and the subscription to Bottles & Extras, will not be processed until payment is received.

Check or money order, in the amount of $75, can also be mailed, made payable to:

The Federation of Historical Bottle Collectors

and send to: 
The Federation of Historical Bottle Collectors
Bottles & Extras
401 Johnston Ct., Raymore, MO 64083

If this form fails to submit online, you may print a copy of the following document.
Then mail your completed application with your payment.

Club Membership Application (Adobe PDF File)
Requires Adobe Acrobat Reader to view and print this file.