Members help DMCHS grow!

Yes!  I want to be a member!

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

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