Name:______________________________________________________

Address:___________________________________________________

City:______________________________ State_______ Zip:________

Home Phone:________________ Work Phone (optional):_________________

Email Address:______________________________________________

___:New membership        ___:Renewal

The Nebraska Bead Society reserves the right to print the above information in our local directory unless otherwise stated. (It will NOT however be posted on the website without your express permission)

Check if appropriate __: Please DO NOT print my name and address in the directory.

Make your check for $18 payable to the Nebraska Bead Society Send this application and the check to Nebraska Bead Society, P.O. Box 30633, Lincoln, NE 68503-0876.

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Member's Signature: ________________________________________________