Name ______________________________Address ___________________________________________
City, State, ZIP _____________________________________ Phone Number ( ) __________________ Membership Category (Circle One):
- Student-$10.00
- Patron-$250.00
- General-$25.00
- Benefactor-$500.00
- Supporter-$50.00
- Associate-$100.00
*Memorial Only- $30.00
Amount Enclosed __________Circle One: CHECK MASTERCARD VISA
Credit Card Number_________________________Expiration Date __________ |