Circolo Italiano di Boston – Membership Form 2012-2013--

To renew your membership, please print this document, write in the following fields and mail it with a check to the address below.

Membership levels:

Student (please send in copy of Student ID) $15

Single $35

Couple $60

Supporting $90

Benefactor $125

Donation

Membership fee (your cashed bank check as proof) is tax deductible.

First Name

Last Name

Title

Mail address (Street, City, State, Zip code)

E-mail address

Telephone

Fax

Interests:

Topics	Regions
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Please make check Payable to “Circolo Italiano di Boston” and mail it to Barbara Lloyd, 2 Mercer Circle, Cambridge, MA 02138.