For annual membership, please print out and complete the application form and mail it, with your check to:
55 NE 2nd Avenue
Delray Beach, FL 33444
561-276-9797 tel • 561-276-1932 fax
www.workshop.org • info@fotofusion.org
You will receive your INFOCUS Membership Card in the mail
Member Information:

Name___________________________________

Addl Name(s)_____________________________
Family & FamilyPLUS Memberships

Address_________________________________

City_____________________________________

State_______________Zip__________________

Occupation_______________________________

Years in Photography_______________________

Age________________Sex_________________

Daytime Tel______________________________

Evening Tel______________________________

E-mail Address___________________________

Computer Choice: ___ Windows ___ Macintosh

Select Membership Level:

___$70 (Individual)
___$100 (Family)
___$125 (FamilyPLUS!)
___$250 (Supporter)
___$500 (Friend) ___$1,000 (Patron)
___$2,500 (Benefactor)
___$5,000 (Grand Benefactor)
___$250 (Community Partner)
___$1,000 (Corporate Member)

Payment Method:

___Enclosed is my check for annual dues, which is made payable to Palm Beach Photographic Centre
___Please bill my credit card:
___VISA ___Mastercard___ Am. Express

Cardholder's Name____________________________

Card#____________________________

Exp. Date_________________________