Membership Form

Contact Information

New Membership Renewal Gift Membership
First Name:
Last Name:
Street Address 1:
Street Address 2:
City:
State or Province:
Country :	USA Canada Other
If Other Country:
Postal Code/Zip Code:
Phone:
Email Address:
Gift From:

Membership Level

	Student	$55
	(Send copy of current Student ID card)
	Senior (age 65 and over)	$55
	Friend	$65
	Associate	$110
	Organization/Corporate	$110
	Extra postage for international members: Canada: please add $5 for postage. All other countries please add $18 for postage

How to Receive Publications

I would like to receive my /Blanket Statements/ via E-mail

I would like to receive my February Directory via E-mail

Quilt-Related Interests

The following information will be listed with your name in the Directory. Please check all that apply.

	Appraiser	Historian
	Author	Industry
	Collector	Museum
	Dealer	Quilt Maker
	Designer	Research
	Educator	Women's Studies
	Folklorist	Other
If "Other" was selected, please indicate what your interest is:

American Quilt Study Group