Friends of C-NET Registration Form

Full Name(s): _________________________________________________________

Address: ____________________________________________________________

              _____________________________________________________________

Phone: ______________________________________________________________

Amount of Donation: $___________________

Date of Donation: ____/_____/______

How would you like to receive your weekly program schedule and quarterly community newsletter?

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Mail to address above

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E-mail to this address: _________________________________________________

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Fax to this number: ___________________________________________________

Gold Members: Please Select one gift

Platinum Members: Please Select two gifts

            T-shirt (Size: ____)

            Baseball Cap

            Ceramic Mug

Platinum Members:

    Please tell us what Program you would like to be recognized in:

       ______________________________________________________________________

I have not yet decided my program
    (we will assist you in the selection process)

Please make checks payable to: C-NET

Send this form and your donation to:

                C-NET
                Viewer Member Program
                243 S. Allen St. Suite 336
                State College, PA 16801

* C-NET will send you a tax deduction receipt upon receiving your donation *