new york staff band
2022 ASSOCIATION
MEMBERSHIP FORM
Name
( Mr ./ Mrs ./ Rank – the way you want it to appear ) Address
E-mail
Contact Phone Number
Membership Level ( check one ) FRIEND SILVER BATON PLATINUM BATON
BRONZE BATON GOLD BATON IN MEMORIAM of
Make a check payable to “ The Salvation Army ”
Check # _____________________________________ Amount $ ____________________________________ Date of Check : ________________________________ OR
MasterCard / Visa / American Express
( NAME OF INDIVIDUAL )
Exp . Date ( MM / YY ): _____ /_____ Security Code ( CVC Code ): __________
Using the envelope provided , please submit this form and payment to :
The Salvation Army New York Staff Band Association 440 West Nyack Road West Nyack , NY 10994
or visit our website www . nysb . org to donate or become a member .