Club Conchylia e.V.

Application:
Herewith I would like to become a member of the Club Conchylia e.V.

First Name: Second Name:
 Street:  No.:
 Postal Code:  City:
 Country:
 eMail-address:



Something about you (optional)
 Telephone:  Fax.:
 Birth Date (dd/mm/yy):
 Collector since how many years?:
 About your collecton:

 Interests, other notes:

 Occupation:
Students, please indicate how long you expect your studies to take:
 Signature:  Date:


Please fill in this form and send it to:


Klaus Kittel
Sonnenrain 10
D-97859 Wiesthal
Germany