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CBQ Membership Renewal Form

Name: ______________________________________________________

Any Changes to Your Information?  (Please Circle)   Yes    No

Membership Category:    (  )   Regular          $35.00

If you answered “No”  above – Stop Here

Address: _________________________________________________________

City: ____________________________State: ___________Zip Code_________

Phone: __________________________Cell Phone: ________________________

E-Mail: _____________________________Birthday: Month/Day_____________


Membership by Mail
Send this renewal form and a check made out to CBQ to:

Terri Klancer

12930 Sleepy Creek Way, Apt 102

Woodbridge, VA 22192

If you would like to have your membership card mailed to you, please enclose a stamped self-addressed envelope with your renewal form and check.


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