New Membership Applications

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First Name:

Last Name:

Title:

Organization:

Street Address:

Street Address 2:

City:

Address State:

Country:

Zip Code:

Home/Office Phone:

Cell Phone:

Email:

Website URL:

Music Type:

Music Format:

mp3

Vinyl

CD

mp4/Video

Club/Station Name:

Club Contact:

Club Contact Phone:

Club City:

Club State:

Club Capacity:

Club Video:

No

Yes

Music Industry Years:

Record Pool Before:

No

Yes

Other Record Pools:

Additional Info:

Pease Enter Code:

Enter Amount

$

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