Please fill out the form

Please fill out the form, print and mail or fax with payment to:

Kevin Harvick Fan Club
703 Park Lawn Court
Kernersville, NC 27284

FAX No: 336-992-2943

Make checks payable to:
Kevin Harvick Fan Club
Membership expires December 31, 2008.

Type of Membership - Prices Listed Include Shipping and Handling

Is this a renewal membership?

Full Name :

Family - Member 2 :

Family - Member 3 :

Family - Member 4 :

Street Address :

City or Town :

State :

Zip :

Phone :

Email :

Date of Birth :

	Visa MasterCard
Card #
Expiration Date:
Card Holders Name:

Card Holders Signature:	______________________________________

Each Membership includes ONE T-shirt, please pick a size :

Additional members from the same household who join also receive a Fan Club T-shirt

Member #2: Member #3: Member #4:

For Office Use Only:
Date Rec'd: _________		Type: ________		Pymt: _________		Date Packaged Mailed: ___________