GEORGIA STATE SQUARE DANCERS ASSOCIATION, INC.

DANCER MEMBERSHIP APPLICATION

(PLEASE PRINT CLEARLY OR TYPE)

NAME: (HIS) -------------------------------------- (HERS) ---------------------------- (LAST---------------------------------------------

STREET ADDRESS:---------------------------------------------------------------------------------------------------------------------------

CITY: ------------------------------------------------------------ STATE------------------------------------------------------  ZIP-----------

 PHONE:  (   -------------------------------- E-Mail ---------------------------------------------DATE--------------------------------------

 LIST CLUB MEMBERSHIP (S)------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------# BADGE STICKERS NEEDED --------------

  CIRCLE YOUR FEDERATION: MASDA, NORTHEAST, NORTHWEST, SOUTHEAST, 

HEART OF GEORGIA, DIXIE, CSRA, E. ALA./ W. GA, OTHER

MEMBERSHIP FEE; $ 8.00 PER PERSON

Please make checks payable to GSSDA and mail to: 

Nancy Feek, 111 Lake Street, Rockmart, GA 30153

GEORGIA STATE SQUARE DANCERS ASSOCIATION, INC.

CLUB / FEDERATION / ASSOCIATION MEMBERSHIP APPLICATION

(PLEASE PRINT CLEARLY OR TYPE)

CLUB NAME----------------------------------------------------Federation---------------------------------------

Contact Person : Name--------------------------------------------PHONE # (       )----------------------------

Address:--------------------------------------------------------------E-MAIL---------------------------------------

City, State, Zip:-------------------------------------------------------------------------------------------------------

Caller:----------------------------------------------------------------  Cuer:------------------------------------------

Dance location:-------------------------------------------------------------- City-----------------------------------

Dance nights; ---------------------------------------------------------------------------------------------------------

Level ( Circle all that apply) : MS, Plus, Advanced, Rounds, Line, Other.

MEMBERSHIP FEE, NEW OR RENEWAL: $8.00

Please make checks payable to GSSDA and mail to:

Nancy Feek, 111 Lake Street, Rockmart, GA 30153