Membership Options:_____ Active ($25/Year), _____ Sustaining ($30/Year), _____ Junior, under 18 ($10/Year)
Name__________________________________________ Phone _________________________
Address_______________________________________________________ Zip_____________
Email_________________________________________________________________________
(Optional): List any literary accomplishments (degrees, publications, prizes, etc.):
______________________________________________________________________________
______________________________________________________________________________
Mail this form with check payable to "Ina Coolbrith Circle" to:
The Ina Coolbrith Circle
Gayle Eleanor, Treasurer,
1245 Pine Creek Way, #J, Concord, CA 94520.
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