THE OFFICIAL FRED MOLLIN FAN CLUB MEMBERSHIP APPLICATION FORM _____________________________________________________________ The Official Fred Mollin Fan Club 3326 NW 52nd Terrace Gainesville, Florida 32606-5852 USA *PLEASE PRINT OR TYPE* ________________________________________________________________________ NAME: PHONE(optional): ________________________________________________________________________ Street Address: EMAIL: ________________________________________________________________________ CITY: PROVINCE: STATE: ________________________________________________________________________ COUNTRY: ZIP OR POSTAL CODE: ________________________________________________________________________ DATE OF BIRTH(optional)(MM/DD/YY): ________________________________________________________________________ OTHER FAVORITES: ACTORS: ________________________________________________________________________ FILMS: ________________________________________________________________________ TV SHOWS: ________________________________________________________________________ AUTHORS: ________________________________________________________________________ MUSIC: ________________________________________________________________________ WHAT ARE YOUR HOBBIES? ________________________________________________________________________ WHAT OTHER FAN CLUBS DO YOU BELONG TO? DO YOU HOLD OFFICE? ________________________________________________________________________ WHAT PROJECTS OF FRED'S HAVE YOU HEARD OR SEEN? ________________________________________________________________________ WHAT QUESTIONS WOULD YOU LIKE TO ASK FRED? (These will be answered in the newsletters. May we use your name? Use back of sheet if necessary) PLEASE USE BACK OF PAGE FOR ANY EXTRA COMMENTS/INFORMATION. THE FINE PRINT: The Fan Club President reserves the right to deny and/or revoke the membership of any person at any time for security reasons.