OMAHA BLUES SOCIETY MEMBERSHIP APPLICATION

(PLEASE PRINT)           Today's Date: ___________________

Name: ____________________________________________________

Address: _________________________________________________

City: ____________________  State: ____  Zip: ____________

Phone #: ___________________  Fax #: _____________________

    
     Annual Dues:         Send check or money order to:   
   Individual     $ 10          Omaha Blues Society
   Charter*       $ 25          P.O. Box #241698
   Donor*         $ 50          Omaha, NE 68124-5698
   Corporate*     $100      
 __________________________________________________________   

 * Charter, Donor, & Corporate Members receive an "OBS 
 Charter Member" T-shirt.  Please indicate T-shirt SIZE if
 purchasing CHARTER, DONOR, or CORPORATE membership:
                           __ Med  __Large  __XL  __XXL

 __________________________________________________________

 Please indicate below if interested in helping in any of
 these areas:
  
 __ fundraising              __ publicity

 __ newsletter               __ data entry

 __ advertising sales        __ phone committee

 __ work OBS desk @ shows    __ anywhere I'm needed