VICA

2007/8 Membership Application/Renewal

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Please print this page, and after completing, mail to:

VICA, PO Box 2022, Venice FL 34284-2022

Make your check payable to VICA

TYPE OF ANNUAL MEMBERSHIP:

______ Sponsoring (Platinum) $150 or above

______ Sustaining (Gold) $100

______ Supporting (Silver) $50

______ Institutional (includes one free single membership) $100

______ Family (2 adults & children) $25

______ Single $15

Your silver, gold or platinum membership entitles you to membership priveleges for your entire family. Your name will also be listed in all VICA materials, or upon request you may be listed as 'anonymous'

______ Please list as 'anonymous'

______ Please list my name

Please Print

Last Name/Organization____________________________________________________

First Name(s)______________________________________________________________

Address___________________________________________________________________

City______________________________ State_______________ Zip_________________

Phone_________________________ Email_____________________________________

Name of Faith Community__________________________________________________

OFFICE USE

Date Received______________________ Date Entered_______________ By___________________

Check #____________ Cash___ Amount________________ Deposited________________________