Baltimore Community Fellows Network
Membership Application

Name:__________________________________________________________________

Fellowship Program Name:_____________________________________________________

Email:__________________________________________

Phone:__________________________________________

Membership Level:

 Tier 1 - $75/year (3 events/year)
 Tier 2 - $250 (24 events/year approx 2 times/month)
 Tier 3 - $500/year (60 events/year – max 5 times/month)

We are limiting use of the Cork Gallery for any Fellow program to a maximum of five times per month.

Please choose your membership level and make a check for the correct amount out to ‘Fusion Partnerships, Inc.” and send it to:

Fusion Partnerships, Inc.
1601 Guilford Avenue, 2 South
Baltimore, MD 21202


______________________________________ _____________________
(Signature) (Date)

Your signature indicates that you have read and understand the policies and procedures in regards to the use of the Cork Gallery Space. You also understand any violation of those policies and procedures may result in the termination of your membership privileges.