The Appliqué Society®

Membership Application

Name:_________________________________________________

Address:______________________________________________

City: ______________ State: _____ Zip+4 ___________ +   ________

                                                                                          (Required 9 number USA Zip Code)

Country: USA     Canadian          International Country: ______________

Telephone: _______________     E-Mail : ___________________

Renewing - Membership # _______________First Time Member

Please mark put an X in the box if you do not want to be notified that
your membership has expired.

What is the name of the Chapter you belong to? ______________________

If none, would you like to become part of a Chapter? ____________________

1 Year Membership

2 Year Membership

TAS Pin

US Resident $20

US Resident $40

TAS Pin $5

Canadian Resident $25

Canadian Resident $50

TAS Pin $6

International Resident $30

International Resident $60

TAS Pin $6

Back Issues of the Newsletter $5 each.     J/F     M/A     M/J     J/A     S/O     N/D Year _____

Check/ money order #____________  $_____._____ made payable to The Appliqué Society® in US Funds

If you are using a credit card you will need to fill out the following information:

VISA        Master Card       American Express         Discover

Credit Card Number: ________________________Exp. Date _____/_____

Name on Credit Card:__________________________________

 

Signature if using credit card: _____________________________

Amount charged $ _________________

Verification number _________

Verification number is the final 3 digits of the number printed on the back of your card.
For American Express, it is the 4-digit number on the front of the card.

Leave Blank for Office Use

N

R            #

Int.

Canada

Pin

Pattern

Date

NL                                             W2

Mail to:

The Appliqué Society

P.O. Box 89

Sequim, WA 98382-0089 USA