Jazz from Bloomington
c/o Monika Herzig, President
3375 E. Old Myers Rd.
Bloomington, IN 47408

Phone: (812- ) 334-3022
Email: mherzig@indiana.edu

Name             
Address             
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.