Name_______________________

Birthday (optional)___________________

Street Address_________________________

City_____________________

State ____________________

Zip ______________________

E-mail Address ________________________

Please complete application and mail along with $20 ($32 for polo upgrade, please indicate size L, XL or XXL) in form of money order or personal check* made payable to “Carl Long Fan Club” to:

Carl Long Fan Club

P.O. Box 1659

Ann Arbor, MI. 48106