Membership Form

2017 Cornucopia of Rhode Island Membership Form

Please Print                                 ______New Membership             _____Renewal

( ) Mr. ( ) Mrs. ( ) Ms. ( ) Dr.

Last Name______________________________________________________________

First Name________________________________________________ MI _________

Home Address___________________________________________________________

City________________________________ State__________ Zip Code _____________

Telephone Number__________________ Email Address_________________________

Institution Address________________________________________________________

City_________________________________ State___________ Zip Code___________

Telephone Number_______________________ Email Address____________________

Please check preferred contact   _______Home    ________Institution

May we share your preferred contact information with other Cornucopia members? 

(  )  Yes   (  ) No

Library Affiliation: (  ) Academic  (  ) Government  ( ) Public ( ) School ( ) Special           ( ) Board/Trustee  (  ) Retired    (  ) Library Student - Name of School:_______________ __________________________________ (  ) Other_____________________________

MEMBERSHIP DUES: $ 20.00_________

Please make money orders or checks payable to: Cornucopia of Rhode Island

Mail To: Ida D. McGhee, PO Box 491, West Kingston, RI 02892

OFFICE USE ONLY

Date: ___________    Payment Type:____________ Deposited: _______________