Membership Application Form

Marblehead Community Access and Media, Inc.

217 Pleasant Street, Marblehead, MA 01945

Phone: 781-631-8213 Fax: 781-631-2263

www.marbleheadtv.org

 

Membership Application

Your membership includes: Ability to vote in Board of Director elections at Annual Meeting; subscription to MHTV newsletter/program guide; open access to training, production equipment, facilities and channel time. All memberships are good for one year.

Membership Categories (choose one):

[  ]   Individual: $25

[  ]   Student (ages 12 – 18): $10

[  ]   Family/Household (family/household members living at the same address): $40

[  ]  Senior (ages 65 and up): Free

[  ]  Organization (Non-profit Organization or Town Department): $50

[  ]  Business: $75

 

Name: ________________________________________________________________________________________________

Organization/Business (if applicable): _________________________________________________________

Address: _____________________________________________________________________________________________

Primary Phone: _____________________________________________________________________________________

Secondary Phone: __________________________________________________________________________________

E-mail address: _____________________________________________________________________________________

If Family/Household, Organization or Business Membership, please list names of members covered by this membership: ________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

FOR OFFICE USE ONLY:

Date Membership Effective: ______________________________________________________________________

Amount Received: ______________________ Check #: ______________________ Staff: __________________

NOTE: See the PDF download page for printable form