Print out this application and fill out all the following
information as accurately as possible.
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Mail to the address at the bottom of this form.
Name:
_______________________________________________________________
Address: _____________________________________________________________
City: ______________________ State: ___ Zip: ___________ Country:
__________
Phone: (Home) ______-______________ Phone (Work) _______-_______________
Fax: ______-______________ E-Mail: ______________________________________
Sponsor / Referred by: ___________________________________________________
Payment Type
| __ Check | __ Money Order | __ Visa | __ MasterCard |
|
Credit Card Number __________________________ Expiration Date ____________________Security code on back of card ____________________ Signature __________________________________ |
Single Membership $50 annually
Dual Membership $75 annually
Send this application with your payment to:
Sarah Siddons Society
500 North Michigan Ave. Suite
300
Chicago,
Illinois
60611