Membership Application Form

To become a member, you can print this page, fill out the following form and mail it with your cheque to
Art Gallery of Northumberland, 55 King Street West, Cobourg, ON K9A 2M2.

If you prefer, you can download the form, complete it and mail it with your cheque to the address above. Click here to download application form. The form requires Adobe Acrobat. If you do not already have this useful free product you can get it here.

Name
Address
City			Province			Postal Code
Telephone			FAX			EMail
Membership Categories (check one)		In addition, I am pleased to enclose a donation of $____________. I will receive a full tax receipt for my donation (See Donor Categories.)
Family ($45)
Single ($30)
Student ($25)
Corporate ($100 minimum)*
Payment by cheque, payable to:
Art Gallery of Northumberland 55 King Street West, Cobourg, ON K9A 2M2

* Corporate Membership includes privileges for up to ten employees.

Membership Donor Categories
(Tax receipt over and above membership.)

Kivas Tully's Circle: $ 50 - $ 99

• Tax receipt for donation
• Recognition in newsletter

William Weller's Circle: $ 100 - $ 499

• All of the above plus recognition for one year in Gallery lobby

Joseph Keller's Circle: $ 500 - $ 999

• All of the above plus copies of Gallery publications
• Use of Gallery for personal functions

Catherine Parr Trail's Circle: $1,000 - $ 4,999

• All of the above plus one free art rental loan

Paul Kane's Circle: $ 5,000 plus

• All of the above plus recognition as sponsor of one exhibit or program.

For sponsorship opportunities, contact the Gallery Charitable business number 118790393RR0001.

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