Printable MPT Membership Form

_____ In addition to my MPT membership, I want to join the MPT Travel Club to save on travel             opportunities while supporting my public television station!

Type of membership (check one):

__________ New Member
__________ Renewal
__________ Rejoin
__________ Additional Gift

Title (check one)

_____ Mr. & Mrs. _____ Mrs. _____ Dr.
_____ Mr. _____ Miss _____ Rev.

_____ Other, please specify: ______________

Name (First, Middle Initial, Last):_________________________________________________

Street Address_______________________________________________________________

City_________________________________________________________________________

State_________ Zip________________

Home Phone (_____)_____________ Work Phone(_____)_____________

Email Address _________________________________________________

MPT Travel Club Membership Payment $75.00
Additional Gift $
Total Payment Enclosed $

Method of Payment

_____ Check or Money Order _____ Credit Card
_____ American Express
_____ Discover
_____ Master Card
_____ Visa
Card Number:___________________________

Signature_______________________________________ Date__________________

Like many organizations, Maryland Public Television exchanges its membership mailing list with
other selected nonprofit organizations as a cost-effective way of developing new supporters.
To indicate your preference please check the appropriate space below.

_____ Yes, I am interested in hearing more about other events and organizations.
_____ Please do not release my name to any organization.

Mail completed membership form along with your payment to:

Maryland Public Television
Membership Department
11767 Owings Mills Boulevard
Owings Mills, MD 21117