Name _______________________________
| Address |
| ______________________________________________ |
| ______________________________________________ |
| ______________________________________________ |
Membership Level
Basic
Level |
||
| __ Student ($15) | __ Individual ($40) | __ Family ($75) |
Contributing Level |
||
| __ Sustaining
($100) |
__ Patron ($200) | __ Friend ($300) |
| __ Francis E Spinner Club ($500) | __ General Herkimer Club ($1000) |
Payment method
__ Check
__ Credit Card
Credit Card Information
__ Visa
__ Mastercard
Card Number_________________________
Expiration Date___________