MAISON FRANÇAISE DE CLEVELAND
ANNUAL MEMBERSHIP FORM
Date Submitted: ________________________
____Mr. ____Mrs. ____Miss ____Ms. ____Dr.
First Name: _________________
Middle Initial: ______
Last Name: ____________________________
Spouse's name, include only if he or she is a paid member:
____________________________________
Address where you wish to receive mailings (required):
____________________________________________
City: ____________________________________
State: ___________
Zip Code: __________________
Home Phone: ________________
Work Phone: ________________
Email: _________________________
Profession: ____________________________________
CHECK ONE: ___New Member ___Renewal (only if dues are current)
CHECK APPROPRIATE CATEGORY:
___Life ($1,000)
___Benefactor ($100)
___Sustaining ($60)
___Household ($45)
___Active ($30)
___Full-time student ($10, proof required)
Your contribution is tax deductible. Please make check payable to:
La Maison Française de Cleveland
Annual dues are for the season beginning in September. Besides the benefits of membership, prompt payment assures inclusion on the mailing list of the Maison Française and notification of our programs and other events in the francophone community.
RENEWAL: You may print this form and send it with your check by regular mail to the Secretary, Dr. Nancy Conrady.
NEW MEMBER: You may print this form and send it with your check by regular mail to the Secretary, Dr. Nancy Conrady. Kindly contact the Secretary by e-mail to obtain the current mailing address.
Thank you for your interest in the programs of our Maison Française. We look forward to including you in our French family.