Georgia Classical Association

Membership and Scholarship Contribution Form

Name ________________________________________________________________

Work Address __________________________________________________________

______________________________________________________________________

Work Phone _________________________ Work Fax __________________________

Home Address __________________________________________________________

______________________________________________________________________

Home Phone __________________________ Home Fax ________________________

E-Mail ________________________________________________________________

Classics Courses You Teach ________________________________________________

ENCLOSED:

__________$20 for 2004-2005 dues

__________ $25 for 2004-2005 patron dues

__________ $ __________for scholarship contribution

$_________ TOTAL ENCLOSED

Please print out this form. Please make your check payable to the Georgia Classical Association and mail to:

Elizabeth Kann
4415 Beachview Drive
Smyrna, GA 30082

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