QRC Membership Form

Please accept my membership:

Name	________________________________________
Street Address	________________________________________
Address (cont.)	________________________________________
City	_____________________________
State	______
ZIP Code	_______________
Home Phone	_______________________
Work Phone	_______________________
E-mail	______________________________
URL	______________________________

Enclosed is my check for my membership level of:

□ $ 25 Friend
□ $ 10 Senior 
□ $ 30 Donor
□ $ 50 Patron / Business
□ $100 Benefactor
□ $1000 Life Member (may be given over 4 years)

I would like my membership contribution to go toward:
     Unrestricted       Consortium of Rhinebeck History      Palatine Farmstead    

Check if appropriate:

My employer's matching gift form is enclosed.

Please make your check payable to Quitman Resource Center for Preservation.
           Contributions are tax deductible within legal limits for income tax purposes.

Mail this form to:
     Quitman Resource Center for Preservation
     P.O. Box 624
     Rhinebeck, NY 12572
 
Please call on me to help with:                        I am also able to help with the following:

Farmstead                                         ______________________________________________
Gardening/Cleanup
Special Events/Baking                     ______________________________________________
Public Relations