Membership Information   New Member    Renewal
                                        annual renewal date is September 30

Type of Membership Individual $15    Student $5   
Organization $30    Sustaining $50    Contributing $100

Personal Data

Name

Address

City

State      Zip Code

Occupation

Business/School Name

Work Phone Personal Phone

FAX

email address

Student Scholarship Donation

Yes, I wish to donate    Amount $

Application & Mailing Information
Print and Mail this membership form with payment to

Jean Montgomery
4544 18th Avenue South
Minneapolis, MN 55407

Total amount enclosed $

Make checks payable to NBS / USITT