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.

Under 30 Discount: If you are under 30 years of age, annual membership is $2.00. (Not prorated.)

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: _______________________________________ (Please print clearly)

Check one:   New ___        Renewing ___

Under 30 discount (check here) ___ 

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

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