The Kentucky State Beekeepers Association

                        Member Information

__Mr. __Ms. __Mrs. __Miss __Dr. __Other, please specify:________________________________

Name_______________________________________________________________________________

Address _____________________________________________________________________________

_____________________________________________________________________________________

City ______________________________________________________      State ___________________

Zip + 4 ______________________________________________

Phone (home)__________________________(work)_________________________________

E-mail address _________________________________________________________________________

Payment enclosed: ____________________

Name of local bee club/association: _________________________________________________

Mail this completed form together with your payment to:

KSBA Treasurer
H. D. Overholt
975 Chapel Hill Road
Adolphus, KY 42120-9773

Make checks payable to KSBA.

Source:  KSBA Website