501 North Fourth, Burlington, Iowa 52601
Name: _____________________________________________________
Address: ___________________________________________________
City/State/Zip: _______________________________________________
Telephone: ___________________ (home) ______________________(work)
E-mail address: ______________________________________________
Annual Membership level (check one):
____ Individual ($15.00) _____ Family ($30.00) _____ Sponsor ($50.00)
____ Benefactor ($100.00) ____ ShoQuoQuon Society ($500.00)
____ Grimes-Salter Society ($1,000.00)
Membership type:
____ Personal ____ Corporate ____ Renewal ____ New Member
Please print and return this form with a check to DMCHS, 501 North Fourth, Burlington, IA 52601