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Membership Application Form

Provided by the Governor Pinchot Group Sierra Club

(Please print this form.)
 
Name:     _____________________________________________

Address:  _____________________________________________

City:     ________________________________________

State:    ______________________________ 

Zip Code: ______________________________

Phone (optional):  _____________________
Membership Categories: (Please Check One) 
Individual:              	Joint:
__ Introductory Rate, $25
__ Regular, $35          	__ Regular, $43
__ Supporting, $50       	__ Supporting, $58
__ Contributing, $100    	__ Contributing, $108
__ Life, $750            	__ Life, $1000
__ Student, $15          	__ Student, $23
__ Senior, $15           	__ Senior, $23
__ Limited Income, $15   	__ Limited Income, $23

For student  memberships, please complete the following:
   __ College Student  or  __ High School Student

   What year do you expect to graduate? ________

Would you like to make an additional gift to the Sierra Club?
   __ Yes    __ No    _______ Amount

Contributions or gifts to the Sierra Club are not tax deductible as charitable contributions. Annual dues include subscription to Sierra magazine ($7.50) and chapter publications ($1), and other member-only benefits. 

__ Check or Money Order (Enclose check payable to Sierra Club)
__ MasterCard or VISA:

   Card Number: ______________________________ 

   Expiration Date: __________ / __________

Enclose check, money order, or credit card information and mail to:
Sierra Club, P.O. Box 52968, Boulder, CO 80322-2968.

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