MEMBERSHIP FORM
Print, Complete and Mail to:
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South Australian Blues Society, 
PO Box 80, 
Hindmarsh SA 5007
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Name: 
Address: 
Suburb:
State:       Postcode: 
Phone(H)
Phone(W) 
Phone(M)
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Tick your selection:
	$25.00 - Renewal Only
	$35.00 - Renewal & T-Shirt 
	$25.00 - New Membership Only 
	$35.00 - New Membership & T-Shirt
	$20.00 - Concession only
	$15.00 - Associate member 
	$20.00 - BLUES NEWS subscription only.
	$2.00  - Post me out my T-shirt.
       	$0.00  - I will pick-up my T-shirt from the Gov'.

TOTAL:$

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If your payment is by Credit Card (tick one)
	MasterCard 
	Visa 
	Bankcard
Name on Card:  
Card Number:  
Expiry Date:       
Signature:
_________________________________________________________        
If your payment is by Cheque or Money Order
Please make cheque or money order payable to:
South Australian Blues Society, 
PO Box 80, 
Hindmarsh SA 5007

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T-Shirt Selection:
	Size(circle one)
	M    L    XL 
	Colour(circle one)
	Black    Blue    Grey