Name ________________________________________________________

Address ________________________________________________________

__________________________________________________________________

Country________________________Postal code (Zip)__________________

Home Phone______________________Work Phone____________________

Fax ________________________________________________________

E-mail ________________________________________________________

Birthdate__________________

Marital status Married Single Widower

Hobbies ________________________________________________________

Special talents____________________________________________________

If you are a member of another beard and/or moustache club, we would like to have a point of contact for future communication.

Name of club ___________________________________________________

Address ___________________________________________________

Phone ___________________ Fax _______________________

E-mail ___________________________________________________

Signature: (required)

_____________________________________________________Date_________