I WISH TO JOIN THE HEROES CLUB

AS A CHARTER MEMBER FOR 1999.

I WISH TO JOIN THE HEROES CLUB

AS AN ASSOCIATE MEMBER.

NAME: 

COMPANY: 

ADDRESS: 

CITY: 

STATE:    ZIP CODE: 

TELEPHONE:  --

FAX:  --

EMAIL: 

SPOUSE*: 

AMOUNT OF DONATION:  $

___________________________________________________________________________________

Make checks Payable to:

    The Heroes Club, Inc.