Kentucky Broadcasters

Association

Special TDGA Membership

Application Form

Please complete by providing the information requested. If you are a new member, you will receive a confirmation and membership kit from TDGA within three weeks, including your wall certificate, TDGA lapel pin and other information regarding TDGA member benefits. (Current TDGA Members will receive extensions through 03/31/2005 at no cost to the member.) If you are interested in enrolling more than one member, please complete an individual form for each member. (This form may be duplicated.)

Name of Applicant: ___________________________________

                                   (Please write or print legibly)

Current Title/Position:__________________________________

Call Letters and/or Group: ______________________________
     (Please include only the Call Letters of Stations for which you are responsible.)

Mailing Address: ______________________________________

Additional Address Info (Apt, Suite, Floor, etc.): _____________

City, State & Zip Code: _________________________________

Telephone: ( ____) ____________ Fax: ( ____)______________

E-Mail Address: (Must Be Included) ______________________

Traffic Software System Used: (for our own information only): ___________ 

______ I am not currently a TDGA (dues-paying) Member, and understand all membership dues will be paid on my behalf by a special cost-free to members program, as a courtesy of KBA.

______ I am currently a TDGA (dues-paying) Member, and understand my membership is to be extended to end on March 31, 2005 at no cost to me.

Please return this completed form, one per individual by mail, fax or e-mail to:

Kentucky Broadcasters Association

101 Enterprise Drive

Frankfort KY 40601

Questions: Please Telephone: (502) 848-0426

Via Fax: (502) 848-5710

Via E-Mail: kba@mis.net or kba@kba.org