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Membership Form


2016-2017 Membership DRIVE 

Use the "Printer Friendly" button at the bottom of the page to print this form out and mail it in!

Name: _________________________________________________

Address: ________________________________________________

City, State, Zip: ____________________________________________

Phone: _________________________________________________

Email: __________________________________________________

o   New Supporter                                  o   Renewing Supporter

Choose your level of support: (Refer to Gift levels online or in brochure.)

o   Benefactor  $1,000

o   Patron   $500

o   Friend   $250

o   Partner   $100

o   Contributor   $50

o   Associate   $25

o   I am sending in the signed matching gift form from my employer

Method of Payment:

Enclosed please find my check in the amount of $__________________

(Make checks payable to San Angelo Cultural Affairs Council)

Please charge my credit card:

___Mastercard            ___Visa           ___American Express                        ___Discover

Credit Card Number:_________________________________

Expiration Date:_______                        Three digit security code:_____

Name as it appears on card:______________________________

Authorized user’s signature:_______________________________

Mail Membership Form to:                  

San Angelo Cultural Affairs Council, PO Box 2477, San Angelo, TX 76902

Phone: (325) 653-6793 

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