LCFC - Membership Application

Please print this page, then fill out the information below and mail it with the membership fee to:

Leslie Charleson Fan Club
c/o General Hospital - ABC, Inc.
4151 Prospect Avenue
Los Angeles, CA 90027

The annual membership fee is $20 ($25 outside United States). Please make your check or
money order payable to Chrissy Holler. Funds must be U.S., drawn on an american bank,
money order, or international money order.

Online payment now available through PayPal.

Name: __________________________________________________

Address: ________________________________________________

City: ___________________________________ State:___________

Zip: ___________

Phone Number: _________________________

Birthday: _______________________________

Email Address: _________________________