Please print out this form, fill it out, and mail it with your check
payable to BROAD UNIVERSE to:
Broad Universe
c/o
1121 E. Vienna Ave
Milwaukee, WI 53212
Required fields are marked with *
If this is a gift, please fill out the form with the recipient's information but
enter your email address as the "donor email address" below in case we
need to contact you.
Member First Name* Middle Last*
_________________________ _________________________ _________________________
Pen Name First Middle Last
_________________________ _________________________ _________________________
List on webpage under [ ] Legal Name [ ] Pen Name
Use for postal mail [ ] Legal Name [ ] Pen Name
(will be used only for renewal notices and checks from book table sales)
Address* ______________________________________________________________________
Address _______________________________________________________________________
City* ______________________________ State/Province* _________________________
ZIP/Postal Code* ___________________ Country _________________________________
Telephone ______________________ Email Address _______________________________
Web Site (url) ________________________________________________________________
Biography:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Recommended by ________________________________________________________________
May we use your name in our publicity materials?* [ ] yes [ ] no
Membership Type* [ ] New member or [ ] Renewal or [ ] Gift
Donor Email Address (for gift)_________________________________________________
Membership Status* [ ] Level One ($30) or [ ] Level Two ($15)
I am also including a donation to the Angels Fund in the amount of $___________
Total enclosed: $____________
Return to the membership page.