Name: _________________________________________________

Address: _______________________________________________

City: __________________________________________________

State: _________________

Zip: ________________

Phone Number: _______________________

___ I want to join the Pikes Peak Jazz And Swing Society to help support the continuation of jazz and swing in the Pikes Peak region. I will receive the monthly newsletter, Pikes Peak Jass Notes, and a membership card entitling me to all benefits of the society. Enclosed is my payment for the following type membership:

___ $5 - Student under 21 years old

___ $20 - Single membership

___ $30 - Family membership