Membership Registration Form

Potter County Fine Arts Council
MEMBER REGISTRATION FORM

Name:

Address:

City:	State:	Zip:

Home Phone:

Work Phone:

Email:

Membership Level:

□ □ □ □ □	Member Level ($10-$29) Family Level ($30-$74) Sponsor Level ($75-$124) Benefactor Level ($125-$499) Corporate Level ($500 and above)


If there is a certain type of programming you would like to have the Fine Arts Council provide, or you have enjoyed particular past programs, please write a brief description below... Thank you. Send completed Registration Form and fees to: Potter County Fine Arts Council PO Box 346 Coudersport, PA 16915