Dean Holmen Charter Fan Club Order form

Please Print and fill out the information below so I can keep real good records of my initial Charter Fan Club Members.

Name  ----------------------------------------------------------------------------

Address --------------------------------------------------------------------------


E-Mail address: if you would like up dates on news or events scheduled.
___________________________________

Birthday (Optional) _________________
Home Phone (Optional)________________

Level you wish to join

$15.00 CD Only:   ______________________
$20.00 Fan Club Member: ________________
$100.00 Friends Member: ________________
$1000.00 Sponsor:   ____________________


Any Checks or Money orders should be made out to 
East Madison Music and mailed to:

East Madison Music
P.O.Box 14464
Madison WI. 53708

Or 
East Madison Music
9 Music Square South # 143
Nashville TN. 37203