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

Amber Tamblyn
The AMTAM Fan Club
c/o General Hospital
4151 Prospect Ave.
Hollywood, CA 90027

The annual membership fee is $20 ($25 outside the U.S.).
Please make your money order payable to Amber Tamblyn.

Name: _________________________________________

Address: ______________________________________________

City:___________________________________

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Phone Number:_________________________

Birthday:_______________________

Email Address:_____________________________