FRIENDS OF THE ALBANY ROUNDTABLE

MEMBERSHIP FORM

Please complete the following form and mail with your contribution to:
Friends of the Albany Roundtable, P.O. Box 7101, Albany, N.Y. 12224

Name ______________________________________________

Address ______________________________________________

_______________________________________________

_______________________________________________

Firm or
Affiliation ________________________________________________

Telephone ____________ E-mail______________________________

Category/
Amount of contribution ___________________________________________

Individual Donor:

[ ] $15 Albany Circle
[ ] $25 Hudson River Circle
[ ] $50 Knickerbocker Circle
[ ] $100 Shaker Circle
[ ] $200 plus 25th Anniversary Patroon

Corporate Donor:

[ ] $100 Corporate Supporter
[ ] $200 Corporate Patron
[ ] $250 plus 25th Anniversary Corporate Benefactor