NYBS Membership Application

NY Blues and Jazz Society Membership Application

Membership Status:
new [ ] renewal [ ]
Select one below:

[ ] 1 Year Single @ $20.00
[ ] 2 Years Single @ $35.00
[ ] 1 Year Family @ $25.00
[ ] 2 Years Family @ $45.00
  NYBS T SHIRTS

____ea large @ $17.00 each = _________

____ea Xlarge @ $17.00 each = _________

____ea XXL @ $17.00 each = _________

includes $2 shipping and handling

Total Enclosed = __________ Check or by Money Order only
Name:        ________________________________________________________

Address:     _________________________________________________________

                   _________________________________________________________

Phone:        _________________________________________________________

Email:         _________________________________________________________

Occupation:     ______________________________________________________

Please print out this form or copy it and return with your remittance to:

NEW YORK BLUES AND JAZZ SOCIETY
134 Overlook Street
Mt. Vernon, NY 10552

Email: info@NYBluesSociety.org