NBS Membership Application
Do you know someone interested in joining USITT NBS? Please pass this membership application on to those
who might be interested. This form is also for membership renewal in September of each year.

Membership Information
New Member         Renewal (Annual Renewal date is Sept. 30)

Membership Type and Dues
Individual $15        Organization $30        Sustaining $50

Contributing $100       Student $5

Note: $5 of Individual dues and $10 of Organizational dues are credited to the Section Student Scholarship Fund.

Personal Data

Name ______________________________________________________

Address ____________________________________________________

City _______________________________________________________

State _________________________________ Zip __________________

Occupation _________________________________________________

Business/School Name ________________________________________

Work Phone _________________ Home Phone ____________________

FAX ___________________ E-Mail Address______________________

Scholarship Fund Donation
Student Scholarship Fund additional donation enclosed in the amount of:


Mailing and Payment Information:
Mail this membership form and payment to:

Jean Montgomery
4544 18th Ave. South
Minneapolis, MN 55407

Please make check payable to: NBS/USITT

Amount enclosed: $________________