American Liszt Society, Membership Form

Please fill out the form below and submit it, then send US funds check (payable to American Liszt Society) to:

Justinn Kolb, Executive Secretary, 1136 Hog Mountain Road, Fleischmanns, NY 12430. Tel: (845) 586-4457; E-mail: <mellon@catskill.net>.

Membership Enrollment Form for ALS, PA Chapter
Membership is by calendar year. Please indicate year of enrollment:  *
New or Renewal?  *
(Fill out the appropriate membership category by entering "YES" in the text field and leave others blank.) Individual membership: $40.00
Student membership: $20.00
Family membership: $50.00
Contributing membership: $100.00
Supporting membership: $250.00
Life membership: $400.00
Family life membership: $500.00
Donor membership: $500.00 (includes life membership)
Institutional membership: $60.00
Chapter Dues: $10.00 (in addition to one of the above categories). Please write "PA Chapter"
I with to help ALS with a contribution of $
Name  *
Last Name  *
Profession  *
Address  *
Street 1  *
Street 2
City  *
State  *
ZIP  *
Home Phone  *
Home Fax
Home Email  *
(Work Address) Organization
Street 1
Street 2
City
State
ZIP
Work Phone
Work Fax
Work Email
I prefer to receive ALS mail at home
I prefer to receive ALS mail at work
If you wish to participate in activities of the Society, please indicate your order of preference. Paper Presentation
Performance
Publish in JALS
Work to develop local Chapter activities
Host concerts in the Home
* Required fields