Garden State Harmonica Club

Annual $25.00 Dues Remittance Form

□ Renewal □ New Membership □Check □ Cash

Please make checks payable to GHSC.

Send this form with payment to:

Garden State Harmonica Club

Attn: Membership Department

P.O. Box 122

Ridgewood, NJ 07451

Your Name: ___________________________________________________

Address: _____________________________________________________

City: _________________________, State: _________, Zip: ____________

Phone: ___________________, e-mail: ____________________________

□ I am a Player □ I am a Listener □ I do BOTH!

OPTIONAL:

Birthday (Month & Day) ____/____, Occupation: _____________________

Spouse’s Name: __________________, Birthday (Month & Day) ____/____

□ I am interested in joining a committee: _________________________

FOR GSHC USE ONLY

□ Membership □ President □ Reed □ Sunshine