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:
 

Jerry Butalla

S69 W22965 National Ave.
Big Bend, WI 53103-9641