Appalachian
Cave Conservancy Membership and Donation Form
ACC is a 501 C 3 Tax-exempt Organization and your contribution is tax deductible.
Date: __________________________
Name:
___________________________________
Birth Date if under 18: ________
This
form is being used to give the family member information only. (No dues are
included) _______
Address: ____________________________________________________________
City:
_________________________
State: _______ Zip Code: _______________
Country,
if not USA: ___________________________________________________
Email:
______________________________________________________________
Home Phone:
______________________ Cell phone: ________________________
Fax: ______________
Work Phone: ______________________________________
NSS member?
_________ Number: _______________________________________
If you wish,
list participation in any land trusts or cave related organizations:
__________________________________________________________________
Dues
and Contributions
|
Individual ACC Membership ___ $10 Regular Member
___ $25 Contributing Member ___ $50 Sustaining Member ___ $100 Benefactor Member ___ $ 250 Life Member ___ Other Amount __________ |
Organizational ACC Membership ___ $10 Regular Organization Member ___ $25 Contributing Organizational Member ___ $50 Sustaining Organizational Member ___ $100 Benefactor Organizational Member ___ Other Amount _______________ |
|
Family ACC Membership ___ $ 15
Family Membership
- Use a separate form for
personal information for each family member. Two people of the same immediate family
living at the same address. Each addition immediate
family member at the same address is $5. + $__.00_ ( ___additional Family Members at $ 5 each ) |
|
|
. |
|
Total
enclosed: $__________
This form
may be downloaded. Mail to
Appalachian Cave Conservancy, c/o Bill Grose, 875 Rolling Hills
Drive, Wytheville, VA 24382.