Membership Form

Contact Information

New Membership Renewal Gift Membership
FirstName:
Last Name:
Street Address 1:
Street Address 2:
City:
State or Province:
Country :	USA Canada Other
If Other Country:
Postal Code/Zip Code:
Phone:
Email Address:
Gift From:

Membership Level

	Student	$55
	(Send copy of current Student ID card)
	Senior (age 65 and over)	$55
	Friend	$65
	Associate	$110
	Organization/Corporate	$110
	Extra postage for international members: Canada: please add $5 for postage. All other countries please add $18 for postage

Quilt-Related Interests

The following information will be listed with your name in the Directory. Please check all that apply.