Membership Signup Form

A commitment to the

Sema Institute

and to Kemetic Culture

PRINT THIS PAGE AND THEN FAX TO (305) 378-6253 OR MAIL TO

Sema Institute Inmate Outreach Program PO BOX 1340 Lithonia GA 30058

(Please Print Clearly)

Name__________________________________

Address________________________________

Apt. #: _________

City______________State________________

Zip_____________

Phone__(_____)__________________________

E-mail__________________________________

ONE TIME DONATION…………………………………………………. Amount $______________

Monthly Membership Level

Institute Donor ($10/mth)……..….$_________

Institute Member ($25/mth)…..….….$_________

Institute Affiliate ($35/mth)…...…..$_________

Institute Associate ($50/mth)……...$_________

Friends of the Institute………..…....$_________

(*Outside USA may be additional fee)

Method of Payment:

(   )  Money Order     (   )  Check

Credit/Debit Card     (  ) Visa      (  ) Mastercard                  (  )  AX       (  ) Discover

#___________________________________

Exp. date (Month/Year):     ______/_______

I authorize the use of my credit card:

____________________________________

Signature______________________________

Check one option below

_____ You may keep my CC# on file and process my membership automatically every month.

______ Charge my credit card only for this one time use. I will call monthly to make arrangements for my pledge amount credit card or will mail my pledge in.

Note: Privileges of the Membership Program Subject to Change

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