BATON ROUGE BLUES SOCIETY MEMEBERSHIP APPLICATION

ANNUAL DUES:

____STUDENT $10   ____INDIVIDUAL $20    ____FAMILY $30   ____BUSINESS $100   ____CORPORATE $250

DATE: __________ 

NAME: _____________________________________

BUSINESS NAME: _____________________________________

ADDRESS: ___________________________________

CITY/STATE: ___________  ZIP CODE: ____________

HOME PHONE (        ) __________  BUSINESS PHONE (        ) ___________

OTHER PHONE (        ) ___________

E-MAIL: ___________________

ARE YOU A MUSICIAN? ______      NAME OF BAND: ______________

WHAT INSTRUMENT DO YOU PLAY? _______________________

HOW DID YOU HEAR ABOUT THE BRBS? _______________________

ARE YOU INTERESTED IN VOLUNTEERING? ______________

ANY COMMENTS OR SUGGESTIONS? ________________________

make checks payable to:
BATON ROUGE BLUES SOCIETY
P.O. BOX 65378
BATON ROUGE, LA  70806-9998
____________________________________________________________________________________
For Office Use Only:

date received: _________ received by: __________

amount received: __________ card no. __________

card sent: __________ expiration date: __________