Potlatch 13 Membership Form
Please print out this form, fill it out, and mail it with your payment to: Potlatch 13 PO Box 31848 Seattle, WA 98103-1848 List any additional names and addresses on the back or on a separate sheet. Name _____________________________________________________________ Address __________________________________________________________ City/State _______________________________________________________ ZIP/Postal Code __________________ Phone ________________________ Alternate Badge Name _____________________________________________ E-Mail Address ___________________________________________________ Please tell us where you found out about this Web page: __________________________________________________________________ [] I want ___ banquet tickets at $22 each (to be picked up at the convention) [] I would like to participate in the writers' workshop [] Tell me about how to create or receive a sponsored membership [] This is an interesting topic to talk/write/act/dance/sing /sketch/kvetch about at Potlatch: ___________________________ _____________________________________________________________ _____________________________________________________________ Amount received:____ Check number:____ Other information requested/comments: __________________________________________________________________ Return to the Potlatch 13 home page This page created and maintained by Anita Rowland |