Arisia Income Form (Rev 9/98)                                                                                                       This area for office use only:
One Kendall Sq., Suite 322, Building 600
Cambridge, Massachusetts 02139                      Account:________________Date Ent:_________________

Arisia, Inc. is a non-profit, tax exempt and tax deductable organization as certified by  IRS code 501-c(3).

Your Name:_______________________________ Income Date:__________ Today’s Date:_________

Type of income (check all that apply): convention registration___, advertising income___, donation ___,
  dealer’s table ___, corporate membership ___, other (specify):_________________________________

If income is an advertisment, dealer’s table, or donation write purchaser info below or attach cover letter.

Purchaser Name:___________________________________________ Phone #:____________________
Address:_____________________________________________________________________________
             _____________________________________________________________________________
City      ___________________________________________________State______ Zip_____________

Detailed List of Income:
From/Purchaser                                                                            Item                       Amount

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Check here if continued on back ___                                                                  Total Amount:____________

Submitted (Corporate Officer/Committee Head//Convention Officer/Division Head/Department Head):

  Name:____________________________________ Signature:_________________________________

Treasurer’s Approval (Signature): _______________________________________ Date: ____________