SOUTHWEST BLUEGRASS ASSOCIATION

DONATION FORM

SEND TO: SWBA - 1013 N. Lyman Ave., Covina, CA 91724

  MAKE CHECKS PAYABLE TO SWBA

Please Print

Date: __________________

Last Name: __________________________________ First Name: ______________________ MI: _____

Last Name: ______________________________ First Name: ______________________ MI: _____

Address: _______________________________________________City:______________________

State: ____ Zip: __________ Phone#: ___________________ E-mail: _________________________

Amount of Donation $_________________

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Optional Donation Combined with Membership (For those who would also like to take this opportunity to join the association):

Please Indicate Choice Below (Check One): 

______$20.00--1 year single, married, family/ Number of children under 18:___________

______$25.00--1 year band, business/ Number of band members:____________

______$40.00--2 year single, married, family/ Number of children under 18:___________

______$6.00---Canadian Postage; or 1st class postage per year; Double for 2 year membership.

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$_____________TOTAL ENCLOSED  (Donation:$______ + Membership:$_____)         

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Make Check Payable to: SWBA;  ENCLOSE STAMPED ENVELOPE if also applying for membership

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OFFICE USE ONLY:     [   ] CASH   [   ] CHECK#________  AMT $ ___________

NOTE: There will be a $25.00 charge for any returned check                             By: ______________________