FRIENDS OF BANSHEE REEKS
NATURE PRESERVE, INC.

MEMBERSHIP FORM

(Membership Year is January-December)

Name:_________________________________

______________________________________

Address:______________________________

______________________________________

______________________________________

Telephone/Home:_______________________

Telephone/Work:________________________

Telephone/Cell:________________________

E-Mail:_______________________________

Please check one:

____ Individual ($15) ____ Student ($5)

____ Family ($20) ____ Organization/Corporation ($100)

Date Paid: ___________________________

I would like to make an additinal donation to support the
work of the Friends of Banshee Reeks: $________
Non-profit status number available on request. Dues and donations are tax deductible to the full extent of the law.

Please make checks payable to:

Friends of Banshee Reeks Nature Preserve, Inc.
P.O. Box 4337, Leesburg, VA 20177
Email: friendsofbansheereeks@yahoo.com

*Thank you*

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