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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                                         ______________________________________________
Special Events/Baking                     ______________________________________________
Public Relations