Alliance Française de Hartford - Membership Form

Date:
Name: 

Address:
City:                                                                                       State:                      Zip:
Telephone -home:                                                 Telephone -work:
E-mail address 1:
E-mail address 2:
Comments
$_______ Basic membership [$35 Single, $45 Family]

$_______ Silver membership [$50 Single, $65 Family]

$_______ Gold membership [$100 Single, $125 Family]

$_______ Platinum membership [$300+]

If paying by check, please make checks payable to Alliance Française de Hartford.
Or pay by credit card:

Visa: _____     MasterCard: _____           

Credit Card Number:____________________________________ Exp. Date:_____________


Signature: __________________________________________________

Mail form and payment to

Alliance Française de Hartford
233 Pearl Street
Hartford CT 06103


Or - register by phone (860-278-9999) or fax (860-293-1688)

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