Name:_______________________
Address: ____________________
City:  _______________________
State: ____________ Zip: _______
Phone: ______________________
Fax:  ________________________
Email: _______________________

Joint membership: Please fill out joint partner name
and address below. Magazine will go to above
address only.

Name:_______________________
Address: ____________________
City:  _______________________
State: ____________ Zip: _______
Phone: ______________________
Fax:  ________________________
Email: _______________________

Are you a: (Please check all that apply)
Spectator ___  Social Dancer ___ Professional ___
Amateur Competitor ___  Pro Am Competitor ___

Method of Payment:
Single membership: check for $45.00 is enclosed ___
Joint membership: check for $65.00 is enclosed  ___

Credit Card:  VISA ___  Mastercard ___  AmExp ___
$45.00 for a single membership
$65.00 for a joint membership

Card Number: ________________________
Expiration Date: ______________________

Card holder signature: ____________________

----------------------------------------------------------------------
Please complete this form and return it with your
payment to: The American Dancesport Organization
PO Box 46191, Madison WI 53744

FAX: (608) 833-1862

For office use only...
Date Received: _____________
M.N. _____   M.P. ______
T.D. _____   M.T. ______