NAME___________________________________________________PHONE____________________DATE______________

ADDRESS____________________________________________________________________ZIP CODE________________

E-MAIL_____________________________________________URL______________________________________________

This is a Gift Membership from_________________________________________________________________________

Address__________________________________City_________________State_______Zip Code______________

Phone____________________________________Email_________________________________________

ARTIST GALLERY MEMBERSHIP $100/YEAR

INDIVIDUAL $40/YEAR - $70/2 YEARS FAMILY $60/YEAR

STUDENT/SENIOR $25/YEAR BUSINESS $100/YEAR

ELECTRONIC MEMBERSHIP $25/YEAR - $40/2 YEARS

DONOR $135/YEAR PATRON $250/YEAR BENEFACTOR $500/YEAR

VISIONARY $1000/YEAR SUSTAINING VISIONARY $2500/YEAR

MY EMPLOYER PROVIDES MATCHING FUNDS

Enclosed is my tax deductible donation $___________ in addition to membership instead of membership

I am a/an ARTIST POET PERFORMER OTHER________________________________________

Check (to Woman Made) VISA MasterCard AmEx

Credit Card #_______________________________________Expiration Date_______________

Signature________________________________________________Amount $______________

The following information is optional and for grant purposes only. Thank you for completing this form.

Racial background:____________________________________________ Age:____________ Income: ________________

Please check how often you will be able to help: ONE TIME MONTHLY WEEKLY

Please check where you would like to help: EXHIBITION WORK GIFTSHOP ART AUCTION

GENERAL OFFICE ACCOUNTING FUNDRAISING

Area of expertise to share with WMG such as design skills, public relations, marketing YES NO

What would you like to offer? _____________________________________________________________________

Which day of the week and at what time is it convenient to reach you: ____________________________________

Signature__________________________________________________________________Date________________