Noteable Blends Membership Registration

First some basic information:

( * indicates required field )

* First Name: Middle Initial: * Last Name: * Address: Address: * City: * State: * Zip ( + 4, if you know it ):

–

* Primary Phone:

––

Secondary Phone: –– Fax: –– Email: * Gender:

Male Female Other

Next, please tell us about some of the things you like– styles of music, favorite coffee, tea, other beverages, and food.
Be as specific as you like in the text boxes:

Select One or More
Basic Music Types:

Not on the list? Type your other favorites here (commas between items, please).

Other Music Types, Artists, Songs, Pieces, Albums, Instruments, etc :

Select One or More
Basic Coffee Types:

Not on the list? Type your other favorites here (commas between items, please).

Other Coffee Types, Coffee Brands, Coffee Drinks, Coffee Houses, Roasters, Brewing Methods etc :

Select One or More
Basic Tea Types:

Not on the list? Type your other favorites here (commas between items, please).

Other Tea Types, Tea Rooms, Tea Brands, Brewing Methods, etc :

Select One or More
Basic Food/Drink Types:

Not on the list? Type your other favorites here (commas between items, please).

Other Food/Drink Types, Favorite Dishes/Drinks, Restaurants, Chefs, Cookbooks, etc :

Finally, please tell us which days and hours you would like the club to be open.

Use a format something like the following example:

Mon: 10AM-6PM
Tue: 4PM-7PM
- - -
Fri: 7AM-12Noon, 2PM-7PM