TRI-STATE JAZZ SOCIETY, INC.
                                                  P.O. Box 896
                                        Mount Laurel, NJ 08054
                                                       
MEMBERSHIP APPLICATION / RENEWAL FORM

Please print this page, fill in this form and mail to the above address with a check made payable
to Tri-State Jazz Society, Inc.  Annual membership will be valid through June 30, 2011.

New Member           Renewal

Regular:        Individual $20                          Couple $40
Sponsor*:      Individual $50                         Couple $70
Patron*:          Individual $100+                    Couple $120+
Supporter:    Individual or Couple $15 (does not include concert discounts)
First and Last Name(s) ______________________________________________________

Street ____________________________________________________________________

City______________________________________________State______Zip___________

Phone (_____)_______________ E-mail ________________________________________

E-mail and Newsletter Options (check all that apply):
             TSJS concert notices
            Newsletter by E-mail              Newsletter by U.S. mail (paid members only)
             Other area traditional jazz events (not sponsored by TSJS)

How did you first hear about TSJS?______________________________________________

Amount Enclosed $________    Date_____________    Check No.__________   Form: Web


* Names of sponsors and patrons are normally published in The Strutter newsletter and on our
   Web site. If you do not want your name included in the list, please check this box: