Membership Application form:

Name: _____________________

Address: _________________________________

City: ____________________

State: _____

Zip: ____________

Home Phone: ____________________

Work Phone: ____________________

E-mail (optional): ________________________

Membership:

_____ New ($20.00)
_____ Renewal ($20.00)
_____ Lifetime ($250.00)

Please mail application with membership payment to:

DIFF
PO BOX 72395
Durham, NC 27722

www.diffclub.com