| New Renewal | |
| Individual | $40 |
| Family/Household | $60 |
| Preservationist | $100 |
| Restorer | $200 |
| Stephen Earle Society | $350 |
(Ms.,Mr.,Mrs.,Dr.) ________________________________________________
Address ________________________________________________________
Tel ________________________ e-mail ______________________________
I/we would like to volunteer, send information regarding opportunities.
My company will match my gift, enclosed is my matching gift form.
Payment $ ________
Cash/Check Credit Card: MasterCard Visa AmEx (please circle one)
Credit card number ______________________Exp. date__________________
Verification Number ____________________Signature. ___________________