Date_________________
Name_______________________________________
Address_____________________________________
___________________________________________
City__________________State_________
E-Mail Address(optional)________________________
Zip____________Phone No.(____)_______________
New Member___ or Renewal___ Would you agree to . . .
Be Nominated for an office?____, or
Be Nominated for a Board Member position?____, or
Volunteer to assist in club activities?____.
Membership dues: $10 per year
Check if you DO NOT want your address & phone number
printed in our membership directory.____
Birthday Information:
First Name:___________________Month/Day____________
First Name:___________________Month/Day____________
First Name:___________________Month/Day____________
Instrument(s) Played:
_______________________
_______________________
Send to:
Bertha Hackett
11408 U.S.Hwy 75
Hoyt, KS 66440