FRIENDS OF BANSHEE REEKS
NATURE PRESERVE, INC.

MEMBERSHIP FORM

(Membership Year is January-December)

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Name:_________________________________

______________________________________

Address:______________________________

______________________________________

______________________________________

Telephone/Home:_______________________

Telephone/Work________________________

E-Mail:_______________________________

Please check one:

____ Individual ($12) ____ Student ($6)

____ Family ($20) ____ Organization/Corporation ($20)

Date Paid: ___________________________

Iwould like to make an additinal donation to support the
work of the Friends of Banshee Reeks: $________

Please make checks payable to:

Friends of Banshee Reeks Nature Preserve
P.O. Box 4337
Leesburg, VA 20175

*Thank you*

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