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