CPW MEMBERSHIP APPLICATION

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Name(Please Print) _____________________________________________________________


Address ______________________________________________________________________


City, State, Zip _________________________________________________________________


Amount Enclosed: ______________________________________________________________         	


Home Phone __________________________________________________________________


Work Phone ___________________________________________________________________


Email _________________________________________________________________________  


Membership Category:

(  ) New Member

(  ) Renewal

(  ) Gift


Membership Level:

(  ) Regular $50

(  ) Student/ Senior (65 and up) - proof of status required $30

(  ) Family $75

(  ) Friend $100

(  ) Patron $250 - Please indicate print choice ____ Ellen Carey 

(  ) Patron $500 ___ Larry Gianettino  ___ Dave Anderson ____ Jeffrey Milstein ___ Yoshi Sugitatsu ____ Noelle Tan


Gift Recipient Name (Please Print)_________________________________________________


Address ______________________________________________________________________ 


City, State, Zip _________________________________________________________________



Amount Enclosed: _____________________________


(  ) Check

(  ) Mastercard

(  ) Visa

(  ) American Express

Credit Card Number: _____________________________________________________________

Security Code: ____________________

Expiration Date: ____________________


Billing Address (if different from Mailing Address) ____________________________________________________________	


Please make checks payable to CPW; MC/Amex/Visa accepted.

CPW welcomes gifts to both our library and permanent print collection.  If you would like to show your support in this way, please call the Executive 
Director, Ariel Shanberg.

Send this membership application to:  
Lawrence P. Lewis, Membership Director
The Center for Photography at Woodstock
59 Tinker Street
Woodstock, NY  12498

The Center for Photography at Woodstock, Inc., was founded in 1977 and is a  tax-exempt charitible organization under Section 501(c)(3) of the Internal Revenue Code.  Your membership and gifts are tax-deductible to the extent allowed by law.

Tel (845) 679-9957, Fax (845) 679-6337

If you are sending CPW e-mail, please include your postal address and 
telephone/fax numbers.

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