Membership Payment Form

Name : ________________________________________________________________

Address : ______________________________________________________________

City: _______________________________________ST: _______Zip: _____________

Email: ____________________________________________________

Home Phone: ______________________________________________

Work Phone: ______________________________________________

________My matching gift form is enclosed

Payment Options:

________Check (payable to Cultural Arts Connection)

________Please bill my credit card VISA Master Card Discover

Card Number ________________________________________

Expiration Date _______________________________________

Signature _____________________________________________ Date: ____________

Mail all correspondence to:

Cultural Arts Connection
Attn: Membership
P.O. Box 365
Lake Zurich, IL 60047