IBM Ring 19
Local Membership Information Form

Please print this form, print legibly, and mail it with your renewal payment ($15.00).

Date: ____________ National IBM #: _________________________________ Name: ____________________________________ Address: _____________________________________________________ City, State, Zip: ________________________________________________ Email Address: ________________________________________________ Phone: _______________________________ (Circle: work or home?) Website: _____________________________________________________ Stage Name: _______________________________ Are you an active performer (circle):      Yes     No Dominant Performance Type __ close-up / walk-around __ street / festivals __ mentalism __ corporate / trade shows __ large / grand stage __ variety performer: Perform for... __ Adults __ Kids __ Mixed __ Comedy focus other talents___________________________________ Additional Information: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Your dues check for $15.00, made payable to IBM Ring 19, may be mailed to: Walt Pattinson PO Box 11446 St. Paul, MN 55111 612-822-3807 Thank you for your membership! Return to the Ring 19 Web Site