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The Academy of American Poets: Membership Form

To become a member of The Academy of American Poets and to start enjoying the benefits of membership, print a copy of the following form, fill it out and send it, along with your payment, to:

The Academy of American Poets
584 Broadway, Suite 1208
New York, NY 10012-3250

MEMBERSHIP FORM

I wish to join the Academy at the following Membership level (check one):

___   Contributing  ($25 to $44)
___   Associate  ($45 to $99)
___   Sustaining  ($100 to $249)
___   Patron  ($250 and above)

I would like to make an additional contribution of $_______.

My contribution will be mached by:

________________________________________

___   I enclose my check, made payable to The Academy of American Poets

Please charge my

___   MasterCard
___   Visa

Acct # _________________________  Exp. Date _________

Signature: ________________________________________

Name: ______________________________________________________
              (as you wish it to appear in Poetry Pilot)

Address: _________________________________________

City: __________________

State: _________________

Zip:___________________

The Academy of American Poets is recognized as a charitable institution by the Internal Revenue Service. The balance of your contribution over $50 is fully deductible for federal income tax purposes.

This page was created on behalf of the Academy of American Poets by

a service of Susannah Greenberg Public Relations.
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