Amended November 11, 2006

APPLICATION FOR MEMBERSHIP

IN THE

GEORGIA ROUND DANCE TEACHERS ASSOCIATION

     NAME: ______________________ ______________________ ______________________
                                 HERS                                     HIS                                          LAST

     ADDRESS:___________________________ _____________________ ________________ _______
                                         STREET                                          CITY                             STATE              ZIP

     TELEPHONE: HOME : (____)________________           BUSINESS: (____)________________________

     Application is for Full Membership _______       Associate Membership _______

     (Requirements are specified in the By-Laws)

     Qualifications: Began Round Dancing in ________________ (year)

                           Began Teaching R/D in __________________(year)

                           Have taught _____ Beginner Classes of _____lessons each.

                           Do you have a BMI/ASCAP License?      _____ Yes       _____ No

                           Teach and cue regularly for R/D Clubs as follows:

     Club Name                                              Day & Time                    Where                                     Level

     ____________________________       ________________       ____________________      _______

     ____________________________       ________________       ____________________      _______

     ____________________________       ________________       ____________________      _______

                                       Cue regularly for the following S/D Clubs

     _____________________________________________________________________________

     _____________________________________________________________________________

     MEMBERSHIP FEE - $10.00 per person yearly                                                           Amount: $___________

     REQUESTING ____ BADGES - $ 6 Each (Pin) $8 Each (Magnet)                              Amount: $___________

                                                                                                                    TOTAL TENDERED: $___________

     I/WE agree to support and promote the ethics of GRDTA and all GRDTA functions.

     Signed_______________________________ Signed___________________________

     Date_________________________________ Date ___________________________

     RECOMMENDED BY GRDTA MEMBERS: ______________________ _______________________