California Betta Society
Membership Form

Your Name (first and last, please)
____________________________________________________________________________ Please provide at least one form of contact information to receive club news:
	1. Your email address:
	2.Your mailing address (required if you wish to receive hard copies of the club newsletters):
	(If you don't want to use your actual address, then for demographic purposes please at least indicate the city {or country if outside the US} you live in.)
	3. Phone number where you can be reached:
	(Please provide at least two different methods of contact if possible.) ____________________________________________________________________________
Responses to the following statements:
	a. "I am currently an IBC (International Betta Congress) member."
	yes             no
	b. "I would like my membership information (name and email address only) published on the web."
	yes             no
	c. "My preferred method of contact is:"
	phone        email
	d. "I would like to receive a hard copy of the newsletter."     (The newsletter will be posted on the web every month that we put one out.)
	yes             no
	e. "I am currently breeding bettas."
	yes             no
	If "yes" please list what types.
	f. "I am interested in:" (fill in from there!)