>Membership Form

Newport Opera House
P.O. Box 351
Newport, NH 03773
 
 

Name _____________________________________________________

Address ___________________________________________________

__________________________________________________________

__________________________________________________________

Phone _______________________E-Mail _________________________

__________________________________________________________
Your Name as you would like it to appear in programs
 

Type Of Membership

___ Corporate >>>>___ Individual
 

Level of Membership

____ Buddy: up to $25.00
____ Friend: $25 
____ Supporter: $50 
____ Patron: $100 
____ Leading Player: $250 
____ Director: $500 
____ Angel: $1,000 
____ Producer (NOHA Event): $2,500
____ Producer (Play): $7500 and above
____ Producer (Musical): $15,000
 

___ Check Enclosed ____ VISA ____ MasterCard
(make checks payable to NOHA)

Name on Card ________________________________________________________

Mailing Address _______________________________________________________

City, State, Zip ____________________________

Daytime Phone (      ) __________________

E-mail ______________________________

Consider our convenient deferred payment option - an automatic monthly charge applied to your card in the following increments:

Card # _______________________________________________________

EXP Date ________________        V-Number ____________ 
                                                        (last 3 digits in signature line on back of credit card)

Signature ____________________________________
 
 

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