Amityville Artists Circle
Founded February 2001 / a not for profit organization
Annual Membership Form

Organization Name:_______________________________

Your Name:____________________________________

Mailing Address:_________________________________

_____________________________________________

Home Phone:___________________________________

Cell Phone:____________________________________

E-Mail Address:_________________________________

Membership Type
Artists,$20.00  Friends / Volunteers,$30.00  Sponsors,$100.
Patrons,$250.

Chosen Membership Type:_________________________

Artists Category:
( Fine Arts, Music, Dance, Creative Writing, Theatre )_____________________________________________
Payable by mail with check or money order made out to Amityville Artists Circle:

Date___ Check / Money order#___ Amount____ Cash____

Please return this from with payment to:

Amityville Artists Circle
P. O. Box 543
Amityville, N.Y. 11701-0543
Registered with N Y Charities and 501(c)Tax exempt status

Phone: (631)598-2182 / E-Mail:amityartists@aol.com