______ Contributor ($25/year) Decal & newsletter

______ Sponsor ($50/year) Lapel pin, decal, & newsletter

______ Benefactor ($100/year) Add book & video to above

______ Lifetime ($1000) Add sculpture to above

______ Business ($100/year) Plaque, lapel pin, decal, &newsletter

This is a ___Renewal Membership ____New Membership

####

______ Contribution in addition to or instead of membership

Name __________________________________________

Address ________________________________________

City/State/Zip ___________________________________

Payment: (Circle one) Check enclosed, VISA/MC

Card # __________________________________________

Expiration _______________________________________

Signature _______________________________________

Total Amount: ____________