On-line Membership Application

E-mail is required to use this on-line form. Some "free" e-mail accounts will not send the completed form. If your e-mail won't send the form when Submit is selected, please use this Membership Application.

Type of Membership

Member Business/Organization
Skip if not Corporate membership

Member Name

Member Name 2
Couple or Family membership only

MailingAddress

City, ST ZIP

Phone
000-000-0000

E-mail

Web Site Address (Corporate memberships)

Your Favorite Blues Club

Your Favorite Local Radio Station

TBS Member Directory
TBS respects your privacy and our policy is to not sell or give membership list information to any other individual or entity outside of the TBS membership. Please select the option that indicates your preference for being listed in the TBS Member directory.
Yes, Put me in the TBS Member Directory
No, I do not want to be in the TBS Member Directory

Payment Option
Please Invoice Me for the membership amount
I will send a check to the address below

Mail membership dues to:
Topeka Blues Society, Memberships, PO Box 4963, Topeka, KS 66604
Do not send cash. Make checks payable to: Topeka Blues Society

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Membership options
• Blues Fan VIP ($60.00)
• Individual ($25.00)
• Family ($45.00)
• Band/Performer ($45.00)
• Corporate/Venue 1 ($100.00)
• Corporate/Venue 2 ($250.00)

Membership Application
Membership Brochure

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Topeka Blues Society, PO Box 4963, Topeka KS 66604 • info@topekabluessociety.org
Kansas Blues Connection • info@topekabluessociety.org

Page Updated on 08/02/08