To become a member of The Academy of American Poets and to start enjoying the benefits of membership, print and complete this form, then send it with your payment to:

Attn: Membership
The Academy of American Poets
584 Broadway, Suite 604
New York, NY 10012-3210

For more information, please contact:

Membership Associate
TEL (212) 274-0343, Ext. 28
FAX (212) 274-9427
membership@poets.org

I wish to join the Academy at the following Membership level (check one):

______ Contributing ($35)
______ Associate ($55)
______ Sustaining ($100)
______ Patron ($250)
______ Sponsor ($500)
______ Benefactor ($1,000)
______ Chairman's Circle ($2,500 and above)

I would like to make an additional tax-deductible contribution of $ ___________________

_____ My company makes matching gifts. I have enclosed the matching gifts form.

_____ I enclose my check, made payable to The Academy of American Poets

Please charge my______ MasterCard______ Visa______ American Express

Acct # ________________________________ Exp. Date ______/______

Signature: ___________________________________________________

Name: ______________________________________________________

Address: ____________________________________________________

City: _______________________________________________________

State: _______________________ Zip:____________________________

Telephone: __________________________________________________

E-mail: _____________________________________________________
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The Academy of American Poets is recognized as a 501(c)(3) charitable institution by the Internal Revenue Service (Federal Tax ID #13-1879953). Our audited financial statements are on file with the State of New York. Your contribution is tax-deductible to the full extent of the law.