Virginia Country Music Associati

First Name:                         Reset Form
Middle Initial:
Last Name:

Street Address:
City:
State:                         ZIP Code:

Telephone Number:

Email Address:

Performing Musician / Artist     Yes    No

Instruments You Play:

Affiliated with Country Music: Yes   No
    How affiliated:

If accepted for membership, I agree to abide by the Constitution and By-laws of the Virginia Country Music Association, incorporated.

Signature: _________________________________________________

Annual Dues of $15.00    Must accompany this application.

V.C.M.A. Use Only

Recommended by: ____________________________________________

Date of Acceptance: __________________

Card Number: _______________________ Expiration Date: _________________