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Name
Address
City ________________________________________, State ____________, ZIP ____________________________
Phone ( )
Email
I would like to volunteer my time and talent to JfB: Yes ________
Special skills
Membership levels:
Student/Senior citizen (over 65) $15
Individual membership $25
Family membership $45
Program sponsorship $100
Benefactor/Underwriter $500
Angels Open dollar amount
Please clip and return this form with your check to: Jazz from Bloomington, c/o Monika Herzig, 3375 E. Old Myers Rd., Bloomington, IN 47408.
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