Name: ________________________

Address: ______________________

          ________________________

Phone: ________________________

Email: ________________________

Date: ____________

   Annual Single Membership is $20.00:

   Annual Family Memberships are $30.00

   Annual Business Membership is $30.00 payable to:

 Print and mail to:

 JCATV

P.O. Box 871

Black River Falls, WI 54615

Membership information will be sent back to you.

Log on to www.jcatv.org for updated information.