The Theodore Burr Covered Bridge Society of Pa., Inc. Membership Application Page

The Theodore Burr Covered Bridge Society of PA is a 501(c)(3)Nonprofit Organization

APPLICATION FOR MEMBERSHIP

PRINT & MAIL APPLICATION TO:

Judy Kuether, Treasurer
1080 5th Ave.
Steelton, PA 17113

Date:__________________
Our Society year runs from October 1, to September 30th

Enclosed are my dues for the class membership I have checked below.

(See note below to pay dues through PayPal)

( ) New Membership ( ) Renewing Membership

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( ) Individual $15.00

( ) Group or Club $20.00

( ) Business $20.00 (if you wish to list your business name; if not, you may join as an individual)*

( ) Couple/Family at the same address $20.00

( ) Lifetime individual $250.00

( ) Lifetime Couple at the same address $400.00

( ) Donation to Bridge Preservation Fund (Circle) $10, $20, $30, Other Amount $_____

( ) Check here if you want to receive a membership card

NAME:______________________________________________________________________________________
[If a couple, please include wife's name. Ex. John J. (Mary C.)]

ADDRESS:__________________________________________________________________________________

CITY:_______________________COUNTY_____________STATE___ZIP:___________________ (9 digits)

TELEPHONE_____________________ EMAIL ADDRESS____________________________________________

My occupation, business or profession____________________________________________________________
My hobbies are:_______________________________________________________________________________

Tell us how your heard about our Society___________________________________________________________

*If you represent a business or club, please identify it by its full name:
_________________________________________________________________________

New members and current members may pay their dues through PayPal (does not apply to Lifetime memberships). Log in to your PayPal account and send your membership dues to: ebridge59@verizon.net. Your dues will be sent to Treasurer Judy Kuether. Please add $1 to your total dues to help offset PayPal fees.