Name:_________________________________________

Address:_______________________________________

_______________________________________________

_______________________________________________

Phone: (home) ___________________________

(work) ____________________________

Employer: ______________________________________

Check one:

1Regular $40.00

1Senior (62+) $35.00

1Youth (17-) $10.00

1Contributing $41.00 - $59.00

1Sustaining $60.00 - $149.00

1Silver $150.00 - $299.00

1Gold $300.00 - $499.00

1Platinum $ $500.00 and up

Please consider a tax-deductible contribution over basic dues.