Name______________________________________________ Date__________________

Address _____________________________________________________________________

City _____________________________________ State __________________

Phone___________________________________ Email __________________________________

Website URL if joining as a business:_____________________________________________________

Committee you’re most interested in (please check at least one):

What brought you to this organization?

* Please enroll me or my organization for the following membership:

Individual $20
Family (2 adults and children under 18)$35
Non-Profit Organization $50
Small Business $250
Corporate Partner $500
Benefactor $1000 and up

Mail to: Space Coast Blues Society - Space Coast Blues Society, PO Box 320333 - Cocoa Beach, FL 32932
E-mail: info@spacecoastblues.org