MO Blues Association, Inc - Membership 

Please complete all that apply so our 
database stays current & helpful!

Date __________ New __  Renewal__ 

Referred By:  ____________________________	

Annual Dues:
		
_____ Student $15.00		_____ Band  $30.00	
							
_____ Individual $20.00		_____ Business  $75.00		
			
_____ Family $30.00		_____ Non-Profit $30.00					
		

Name ____________________________________________________________
Business, Band, Organization, Individual, Student  OR   
List all names for family membership

Business/Band Contact Person _____________________________
Phone (___)______________
Band Members _____________________, _____________________,
__________________,___________________,____________________
(Use back of form for additional band member names)

Mailing Address ________________________________________________

City __________________________State ___________ Zip ___________

Home phone (_____)_____________ Work phone (_____)______________

Other phone contact (_____)____________ Fax (_____)____________

Email PLEASE (please print clearly)_____________________________
Web Site for Business & Band Members ___________________________
*_____* Opt to receive the Newsletter via email or on-line 
(We hope to have this delivery system perfected in 2007)
		






Your talent may be just what we need to grow!  
Committee Interests:

___ Blues in the Schools ___ Newsletter Contributor ___ Membership

___ T-Shirts/Merchandise ___ Grant Writing ___ Festival 2007

___ Publicity		___ Jams	___ Nominating Committee 
	
___ Special Events ___ Blues Blast IBC Contest __  Holiday Party

___ Summer BBQ In The Park    ___ Web site    ___ Raffles & 50/50s
					

Please share ideas or suggestions to make the 
MO Blues experience bigger and better:  
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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Please Return this Form and Dues to: 
MO Blues Association, Inc., PO Box 105758, JC MO 65110-5758






Board use only: 
Paid $_________ (check/cash/PayPal)   ___Mailing Labels 
___Data Base  ___Email List  ___Website ___Welcome Call  
___Welcome Letter ___Membership Card     
_____/______ Expiration month/year