Single_______ Married________ Date________
Name___________________________________________________________________
First Name Last Name
Spouse’s Name___________________________________________________________
Address_________________________________________________________________
City_______________________________ State______________
Zip_______________
Phone______________________________
E-mail______________________________
Occupation___________________________
Birthday: Man______________________
Birthday: Woman____________________
Anniversary_________________________________ (month & day only)
Additional Information – please check if applicable:
______ Band Leader ______ Hall Owner
Name of band, hall, or organization______________________________________________________
Make Checks Payable to: Wisconsin Polka Boosters, Inc.
$18.00 / year per person or per
married couple.
Please print this page, fill out
and send to:
Debbie Cardassi
2528 S. 96th St.
West Allis, Wi. 53227
Thanks for becoming a Wisconsin Polka Booster Member...