Single________        Married________        Month________        Date________

Name___________________________________________________________________

                   First Name                                                 Last Name

Spouse’s Name___________________________________________________________

Address_________________________________________________________________

City_______________________________ State______________

Zip_______________

Phone______________________________

E-mail______________________________

Occupation___________________________

Please check if applicable: Band Leader (    )        Hall Owner (    )

Name of Band, Hall, or Organization________________________________

New Member being sponsored by___________________________________

Membership Fee: $22.00 per person or couple

For more information call: Kathy Draver at 414-761-0750

Make Checks Payable to: Wisconsin Polka Boosters

Please print this page, fill out and send to:
 

Kathy Draver

6631 S. 26th St.
Oak Creek, WI 53154

Thanks for becoming a Wisconsin Polka Booster Member