(Print this form and mail with payment to the below address)

NAME:______________________________________

ADDRESS: ___________________________________
CITY/ST/ZIP:__________________________________

PHONE: _____________________________________

DATE:________________

CIRCLE ONE:

• Individual $10.00
• Couple $15.00

AMOUNT ENCLOSED: _______________________

Make Check or Money Order Payable to:
The Hull Pottery Association
c/o Nancy Ankeney
4201 Brentwood Drive
Columbia, MO 65203