Wabash Valley Musicians Hall Of Fame, Inc.
                                     Questionnaire


Date ___/___/___

This questionnaire is for:

___ Myself

___ Someone I would like to have considered for induction into the Hall of Fame

___ Someone I would like to have considered for induction into the Band of Angels

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Complete this section if the questionnaire is not for yourself, otherwise leave blank:

Name __________________________________________     Telephone (_____) _________________ 

Email _________________________________________________________________________________

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Complete this section for the person to be considered (yourself or someone else):

Name    _______________________________________     Telephone (_____) _________________ 

Address _______________________________________________________________________________

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Email   _______________________________________________________________________________

Age _____       Years Performed ______       Years Performed in the Wabash Valley _____

What instrument(s) do you play?

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What style(s) of music do you play?

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What bands have you worked with?  Be as complete as possible, include years where known.

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You may use this form in one of the following ways:

(1) Print the form, fill it out, and either give it to a Board Member, take it to The
    Music Shoppe or Rick Waggoner's State Farm Insurance office, or mail it to:

    Wabash Valley Musicians Hall of Fame
    P.O. Box 3187
    Terre Haute, IN  47803

(2) Do a Save As from your browser to save a copy of the form on your computer, open the
    file in Notepad, fill it out, save your changes and email it to us as an attachment.