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FOR THE USE OF CURRENT MEMBERS ONLY
Please do NOT send money if you are not a current member.

Member Registration Form
We ask that all members furnish this information annually in order to keep our records up to date.
Dues are $40.00

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NAME: ____________________________________ DATE: __________________

ORGANIZATION (if applicable): __________________________

ADDRESS: _________________________________________

CITY: _________________ STATE: _______ ZIP: _______________

PHONES: (Day) ____/____-_______ (Night) ____/____-_______

FAX: ____/____-_______

E-MAIL (will be encrypted to prevent spam): ________________________

WEB SITE (if any): http://                                            

Please check appropriate box:    Author Member    Associate Member



Please check the box/es that apply in the form below to inform us of your intentions.
         Patron Level: A gift of $500 or more.

         Sponsor Level: A gift of $250 or more.

         Fellow Level: A gift of $100 or more.

         Donor Level: A gift $50 or more.

         Friend Level: A gift of any amount.

         Dues only: $40.00

Enclosed is my check for $_______________ (payable to Society of Midland Authors).

Mail to (Please do not send money unless you are a current member.):

Society of Midland Authors
P.O. Box 10419
Chicago, IL 60610