| __ New Membership __ Renewal Membership __ Information Change Please Print All Information |
| Last Name ___________________________ First Name __________________________ Middle ____ |
| Address ____________________________________________________________ Apt/Suite _______ |
| City ____________________________________ State ____________________ Zip code ___________ |
| Phone No. (Home) _____________________________ (work/cell ) ______________________________ |
| D.O.B. _______________ Age ________ Profession ________________________________________ |
| Web Page URL ______________________ E-Mail Address ____________________________________ |
| MEMBERSHIP CATEGORIES All minors must be sponsored by an adult member |
| ARTISTS and/or MUSICIAN -- Performers Only |
| __ Country Artist/Musician $10.00 __ Gospel Artist/Musician $10.00 __ Bluegrass Artist/Musician $10.00 |
| __ GENERAL PUBLIC Individuals Membership $10.00 |
Signature______________________________________________________ Date ________________ |
I agree with the goals of the Buckeye Country Music Organization of America.
This membership is subject to approval and is an annual membership agreement.
The B.C.M.O.A. is an affiliate of the North American Country Music Association
International, Inc.
This membership is subject to approval and is an annual membership agreement.
The B.C.M.O.A. is an affiliate of the North American Country Music Association
International, Inc.
| Please Print and Mail to: BCMOA 4819 Warminster Dr. Columbus,Ohio 43232 614-866-7573 |
| OFFICIAL USE MEMBERSHIP #: _______________ Date Accepted: ______________ Date Paid: _____________ Amount Paid: ____________ Money Order/Cash |