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, 2012.

New Member           Renewal

Regular:         Individual $20                                         Couple $40
Sponsor*:      Individual $50                                        Couple $70
Patron*:          Individual $100 or more $_____         Couple $120 or more $_____
First and Last Name(s) ______________________________________________________

Street ____________________________________________________________________

City______________________________________________State______Zip___________

Phone (_____)_______________ E-mail ________________________________________

E-mail and Newsletter Options (check all that apply):
             Send newsletters and TSJS announcements by e-mail
            Send newsletters by U.S. mail (paid members only)
             Send e-mail announcements of other traditional jazz events not sponsored by TSJS

How did you first hear about TSJS?______________________________________________

Amount Enclosed $________    Date_____________    Check No.__________  

* 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: