Gallery Guild Application (Please print, fill out, and mail to us.)

Name: _______________________________________________________

Address: _____________________________________________________

City: __________________________________________ State: _________

Phone: (_______)__________________________

email: _____________________@_________________________________

Check one of the following:

___ Student/Senior -------- $10

___ Member --------------- $25

___ Sponsor -------------- $100

___ Benefactor ----------- $500

___ Other ---------------$ _______