Mail this form to:
GLT   -  P.O. Box 315   -  Oxford  -  NC  -  27565

I wish to Become a Patron of Granville Little Theatre
Enclosed is my Tax Deductible Contribution for:

$ ____________________
Fill in the amount of your donation

I would like the Playbill to list my name as:

_________________________________________________
Your Name, Company Name, or Group's Name
for example..,     Mr. & Mrs. Jim Smith,  Janice Carson
Granville Graphics, Stovall's Gifts and Collectables

Your Full Address:

__________________________________________________

__________________________________________________

City ______________________________________________ 

State _____    ZIP _____________       

We need a Phone Number of Phone Number's where we can contact
you to confirm your listing

___________________________________________________

___________________________________________________
(Area code and telephone number please)

Is there anything you'd like to ask, suggest or tell us?

___________________________________________________

___________________________________________________

Thank you, you will receive a Tax Receipt for your contribution by mail!