Name:________________________________________________________ Phone: ___________________________________

Address:________________________________________________________________________________________________

Town, State, Zip code:_____________________________________________________________________________________

Please Fill In Level of Support:

             Friend             up to $35           $______
             Supporter     $36 to $99          $______
            Ensemble      $100 to $249      $______
            First Chair    $250 to $499       $______
            Soloist         $500 to $1,000     $______
           Conductor
     over $1,000        $______

Please note if you would like to volunteer or be contacted by a member of the Board of Directors:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Quartet Club

Please enter your Quartet Club pledge information as follows:

(List your name as you would like it to appear in our programs and on our web-site)

Name:__________________________________

Address:________________________________

City:_________________________State:_____

Zip:____________

Telephone:_(_____)_________________________

While you may pledge any amount, may we suggest:

$ 100 per year for four years: ______
$ 250 per year for four years: ______
$ 500 per year for four years: ______
$1,000 per year for four years: ______
Other: $ ________ per year for four years: ______

Please print this form page and fill in your pledge information. Mail it to the above address along with your check made payable to “Shepaug Friends of Music.” Thank you!

Please make checks out to:
Shepaug Friends of Music
Mail to:
Shepaug Friends of Music
P.O. Box 83
Roxbury, CT 06783