Mozart Society of America

Membership Form

I would like to become a member of/renew my membership in the Mozart Society of America.

Name (First): ____________________________ (Last): ___________________________

Address: _______________________________________________________

City: ____________________________ State/ZIP: _______________________

E-mail: ___________________________________________________

Phone (optional): ________________________ Fax (optional): _______________________

Institutional Affiliation: _______________________________________________

Annual dues:

Regular: $40
Emeritus/Student (full-time): $25
Sustaining: $80
Patron: $200
Life membership: $1,000

Membership year runs from 1 July through 30 June.

I am enclosing my check in the amount of $________ , payable to the Mozart Society of America.

I would like to make an additional contribution of $________ to aid in the founding of this Society.

Signature: ______________________________

The Mozart Society of America is a non-profit organization as described in section 501c(3) of the Internal Revenue Code.

Please send the signed form with your check to:

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