PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Street Address *Apartment, suite, etcCity *State *Zip Code *Email Address *Phone *Date of Birth (m/d/y). Note: Applicant must be at least 18 years old. *Month *Day *Year *Name of Spouse / PartnerEducation (Please list schools attended and degrees received)Career / OccupationIf retired, please provide name of last employerPrevious Occupation(s)0 / 200Military Service & RankIf applicableMemberships in historical and/or cultural organizations and offices held:Other MembershipsInterestsAwardsPublicationsPlease attach any additional information (CV, publications, etc.) you would like to provide.Upload fileChoose FileNo file chosenDelete uploaded filePlease describe your interest in becoming an Athenaeum Subscriber: *Please describe any recent activity (ie. lectures, visits, volunteering, associates, etc.) with the Portsmouth Athenaeum:Please check one or more Athenaeum committees that may be of interest to you: *AdmissionsArts & ArtifactsBuildingCommunications & PublicationsDevelopmentExhibitsFinanceLectureLibrary & Special CollectionsOutreachPerformanceSocialTechnology AdvisoryThe following three (3) Athenaeum Proprietors have agreed to provide endorsements on my behalf: *Note: Members of the Admission Committee may not be endorsers.For legal purposes, we require your answer to the following question: Have you ever been convicted of a crime, the record of which has not been annulled? *YesNo Submit ApplicationPlease do not fill in this field.
