Name      _______________________________

Address __________________________________________________________________

            ___________________________________________________________________

City, State, Zip _____________________________________________________________

Home Phone (___)___________________   Work Phone (___)_______________________

Place of Employment ________________________________

Wisconsin Background (colleges attended, hometown, etc.)

Interested in volunteer work with the Society on any of the following committees?

Newsletter ___   Cherry Blossom ___  Activities ___    Membership ___

FAX Number _________________ E-mail Address ____________________

Please make check payable to: Wisconsin State Society.

Membership Fees:
Regular $10.00  Family $15.00  Student & Intern $ 5.00   Corporate $100.00

Recommended by ________________________________________

Mail this application with your check to:

Wisconsin State Society
William J. Wagner, President
4122 N. 17th St.
Arlington. VA 22207
H: 703-527-4122, W: 202-366-9349, Fax:202-366-7152

Can you suggest others who would be interested in joining the Wisconsin State Society?

Name _______________________________ Name ____________________