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;National Show Roller Association

New Membership Information

Adult Member________ Junior Member________Age________

Name: ________________________

Address:_______________________________________________

Phone #:___________________ Cell:________________________

E-Mail:________________________________

Band Order: Bands are sold in 50 to 100 bands to a string. And they are $.30 each. 50 bands at $15.00 and 100 bands at $30.00.

Membership Dues are $20.00 for Adults and $10.00 for Juniors.

Please make your check out to NSRA and send to:

Sam Wesley 3709 Pepperell Pkwy Opelika, Al. 36801

Membership Dues $_______________

Band Order Circle one

50 or 100 $______________

Total $_______________

Thank You!