BOTMDG Membership Form

Membership is $12/year, prorated at $1/month. All memberships expire at the end of December. For example, if you become a member in May, you pay $8.00 and your membership expires at the end of the year (like everyone else's), which is 8 months later.

Student discount: If you are a full time student, annual membership is $2.00.

To become a member, you can print out this form and bring it to a dance, or mail it with payment to: BOTMDG , PO Box 3238 , Bloomington, IN 47402

Member Name: _____________________________________________

Address: __________________________________________________

City: ________________________ State:_______ ZIP: ________ (Please include the ZIP)

Phone: _______________________

Email Address: _______________________________________

Check one:   New___       Renewing___

Senior or Student discount (check here) ___ 

Amount paid: $____________    Form of payment: Cash ____ Check____

(For BOTMDG use: Received by (Board Member: __________________ Date: ___________ )