DATE ____________________________________
NAME ___________________________________________________
ADDRESS ________________________________________________
CITY _______________________________________
STATE ___________ ZIP ______________________
PHONE ____________________________________
E-MAIL ____________________________________
BIRTH MONTH & DAY _________________________
If you are an artist, what medium(s) do you prefer to work in? _____________________________________________
_____________________________________________
DUES: ( ) INDIVIDUAL $20
( ) FAMILY $30
( ) SPONSOR $100
( ) PATRON $150