chicago blackhawks coaches club

CHICAGO BLACKHAWKS
COACHES CLUB
Supported by Athletico & gunzo’s
Coaches Name: Address:
City:
State:
Zip:
Email Address:
Phone Number:
Gender (Circle one):
Male
Alt Phone Number:
Female
Check Off Current Coaching Level:
LTS
Mite
Squirt
Pee Wee
Bantam
High School
Midgets
College
2009 - 10 Club(s):
CEP Certification Level (circle one):
1
2
3
4
5
Payment Information:
Circle One:
VISA
AMEX
MC
Check #:
Card #:
PLEASE TAKE THIS FORM
AND EITHER FAX OR MAIL
TO THE FOLLOWING:
FAX NUMBER:
Exp. Date:
Security Code:
MAILING ADDRESS:
Name on Card:
CHICAGO BLACKHAWKS
COACHES CLUB
Signature of Card Holder:
silver membership:
312-455-7070
1901 WEST MADISON STREET
CHICAGO, IL 60612
$20.00
(Includes quarterly emails, exclusive gift, 2 tickets to Blackhawks Training Camp Festival and more.)
CHECKS PAYABLE TO:
CHICAGO BLACKHAWKS