The Blues Blowtorch Society Membership Application

Name ___________________________________________ Start Date ___________________

Address ________________________________ City _______________________ Zip________

Phone # ______________________ Email Address _________________________

Would you like to Volunteer? YES, Interest_________________________________ no

Membership Types:

Individual ($20/Yr)_______

Family ($25/Yr)_______

Student ($10/Yr) _______

Corporate ($100/Yr)_______

Preferred Corp $(TBD) by individual event

Make checks payable to:

The Blues Blowtorch Society
c/o Frank Black
R. R. 2, Box 5
Clinton, IL 61727