Name: ____________________________________
( Please Print as you would like it to appear in print)

Address: __________________________________

__________________________________________

Phone (Home ) : ___________________________

Phone (Business ) : _________________________

Email Address: ____________________________

I have enclosed my payment in the amount of :
$_____________ ($25.00 minimum donation)

Payment Options:

Check
(Payable to Williamsport~Lycoming Arts Council)

Cash

MC or VISA ( Circle One ) / Card Number:

_________________________________________

Signature : ________________________________

Exp. Date : ________

Memberships are tax deductible !!

I would like to Volunteer, please contact me
about varied opportunities.

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