| __ Individual | $25 | __ Senior (age 60+) | $20 |
| __ Household | $35 | __ Sponsor | $125 |
| __ Full-Time Student | $20 | __ Corporate* | $200 |
| * = Corporate membership includes a free company listing on our website. | |||
A One-Year Membership Includes:
Print name as it should appear on Membership
Card:
| Please Select: | __ Mr. & Mrs. | __ Mr. | __ Mrs. | __ Ms. | __ Miss | __ Dr. | __ Esq. |
Name(s): _______________________________
Address: _______________________________
City: ______________ State: ___ Zip: _____
Phone: _______________Email Address: _________________________
If giving a Gift Membership, please fill
out below.
The above Gift Membership is a gift FROM:
Name(s): _______________________________
Address: _______________________________
City: ______________ State: ___ Zip: _____
Phone: _______________Email Address: _________________________
| Membership | $______ |
| Gift Membership | $______ |
| Additional Tax Deductible Donation | $______ |
| TOTAL | $______ |
Enclosed is my check payable to:
The Foundation for Historic Building Rescue, Inc.
Please return completed form and your check
to:
The Foundation for Historic Building Rescue, Inc.
828 Main Street, Harleysville, PA 19438