First Dutchess Quilters

Membership Form

Sept. 2011 - June 2012

Name:___________________________________________________________

Street:___________________________________________________________

Town, State, Zip___________________________________________________

Phone:_______________________________________

E-mail address_____________________________________(please print clearly)

Your contact information will be included in a printed guild directory which will be made available to all members in November.

!!! Note: All newsletters and notices will be sent by e-mail unless otherwise requested.

If you prefer to receive them by post,

please indicate by checking here:___________

Please check one of the following:

I am a new member____________

I was a member in 2010-2011 and am renewing_____________

I am a returning member who did not join in 2010-2011____________

If you were a member last year and there are any changes in your name, address, phone number or e-mail address, please specify here:___________________________________________

_________________________________________________________________

Occasionally, our membership list is requested by speakers or local shops to use as a mailing list. Would you like us to release your name, address and/or e-mail in response to these requests?

Yes_________ No__________

If you have any questions, comments or suggestions for the membership committee, please list them here: ______________________________________

_______________________________________________________________________

Membership Dues are $30.00 per year. ($15 after Jan 1^st)

Please make checks payable to "First Dutchess Quilters"

Please return this form with your payment to:

Joyce Brower

33 Pine Hill Road

Pleasant Valley, NY 12569

Membership Committee use

Paid via: Check___________ Check #__________Cash_________

Rec’d By:_________________ via Mail_________ In Person______ Date_________