Name:_____________________________________________________________
     ^{(Last)                 (First)                       (MI)}
Street Address:___________________________________________________

City/State:_______________________________________________________

County:______________________

Phone: (Home)_____________________________________________________

       (Business)_________________________________________________

I accept your invitation to join the Sandhills Writers Conference Membership or renew my Membership at the level indicated below:

_____ Friend: up to $99 _____ Patron: $100- $249

_____ Enclosed is a check in the amount of $___________

_____ Please bill my credit card: _____ Visa or _____ MasterCard

Friend: up to $99 receives Program Recognition and two reserved seats at all readings
Patron: $100-$249 receives Program Recognition, four reserved seats at all readings, as well as one signed book from Keynote Author

Card Number:_________________ Expiration Date: _____________
Cardholder’s Name:___________________________
Signature:___________________________________
E-mail:______________________________________
Date:_______________________________________

_____ Check here if you printed out this form via the Sandhills webpage.

Mail application with check, money order, or completed charge information to:
Augusta State University
Division of Continuing Education
2500 Walton Way
Augusta, GA 30904-2200