Bucks & Does - Membership Form

Bucks & Does
Western Singles Square Dance Club
P. O. BOX 332
COLUMBUS, OH 43216-0332

MEMBERSHIP APPLICATION

Please print all information as requested. Please do not leave any blanks. Give form & dues to the Council Representative (or other officer present) or mail it to the above address.
Please date and sign your name in the space provided following the declaration statement.

NAME:

D.O.B:

(Last)

(First)

(MI)

(Mo/Day)

ADDRESS:

(Street)

(Apt.)

(City)

(State)

(Zip Code)

(County)

PHONE:

(Please include Area Code)

(Home)

(Work)

EMAIL ADDRESS:

Phone & E-Mail will be listed in the roster as shown. Only include the numbers or information you want in the roster.

MARITAL STATUS:

Single Separated Married

(Please check one)

(Single is never married, divorced, or widowed)

I declare that the marital status I have checked above is accurate.

SIGNATURE:

DATE:

PLEASE ALSO ANSWER THE FOLLOWING:

I received Western Square Dance instructions from:

Caller's Name and Club:

My Dance Level Is:

Mainstream Plus Advanced Challenge

Dues:

For Period

Badge:

Name Bar:

Payment Received...

TOTAL:

Check#

Cash:

Name as it should appear on the name bar:

DO NOT WRITE BELOW THIS LINE

President:	Pres-Elect:	Past-Pres:
Treasurer:	Treas-Elect:	Council-Rep:
Secretary:	Sec-Elect:	Con-Rep-Elect:

ONLINE NEW MEMBERSHIP FORM (20080310)