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___ New Membership ___ Renewal
Membership
Membership Level
| ___ Student ($25) |
___ Filmmaker ($50) |
| ___ Household ($75) |
___ Senior Citizen ($25) |
| ___ Non-Profit Organization ($125) |
___ Corporate Membership ($225) |
Payment
Your IMAGE membership is a tax-deductible contribution.
Please make checks payable to IMAGE Film & Video
Center. You may also charge your membership to your
VISA or MASTERCARD.
Check # ______ or
___ Visa ___ MasterCard
Cardholder Name ______________________________________
Card Number _________________________________________
Expiration Date _______________________________________
Signature ____________________________________________
Want to Volunteer?
| ___ Atlanta Film Festival |
___ Membership Events |
| ___ Screenings |
___ Other |
Your Contact Information
Name ____________________________________________
Address ___________________________________________
Address ___________________________________________
City ______________________________________________
State/Province _____________________________________
Zip/Postal Code ____________________________________
Occupation ________________________________________
Work Phone _______________________________________
Home Phone ______________________________________
E-mail ____________________________________________
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