Friends of Point Pelee - Membership Application

Name:________________________________________

Address:______________________________________

_____________________________________________

_____________________________________________

Phone: (___)___________________________________

Email:_________________________________________

Date:__________________________________________

Please Select Membership (Canadian Funds):

___  $15 SINGLE

___  $20 FAMILY

___  $50 SPONSOR - Includes single membership and a $35.00 tax receipt

___  $500 PATRON - Lifetime membership and a $350.00 tax receipt

Donation Amount (Do NOT Send Cash in the mail):

___  $25        ___  $50        ____  $100        ___  $200        $__________

Method of Payment:

___  CHEQUE        ___ VISA        ___  MASTERCARD        ___  AMERICAN EXPRESS

Card #:______-______-______-______   Expiry Date: (YY/MM)  _____/_____