Potlatch 13 Membership Form

• Memberships in Potlatch 13 are available at the following rates:
  • $40 until February 15, 2004
  • $20 for people aged 11 to 17. (Under 11 free when accompanied by an adult.)
  • $10 supporting (convert to attending at rate in effect at time of conversion.)
• Make checks payable to "Potlatch 13".

Please print out this form, fill it out, and mail it with your payment
to:

        Potlatch 13
        PO Box 31848
	    Seattle, WA 98103-1848


List any additional names and addresses on the back or on a separate
sheet.

Name _____________________________________________________________

Address __________________________________________________________

City/State _______________________________________________________

ZIP/Postal Code __________________  Phone ________________________

Alternate Badge Name _____________________________________________

E-Mail Address ___________________________________________________

Please tell us where you found out about this Web page:

__________________________________________________________________

  
  [] I want ___ banquet tickets at $22 each (to be picked up at
     the convention) 

  [] I would like to participate in the writers' workshop

  [] Tell me about how to create or receive a sponsored membership

  [] This is an interesting topic to talk/write/act/dance/sing
     /sketch/kvetch about at Potlatch: ___________________________

     _____________________________________________________________

     _____________________________________________________________


Amount received:____   Check number:____ 	


Other information requested/comments:

__________________________________________________________________

Return to the Potlatch 13 home page

This page created and maintained by Anita Rowland