Print this form using your web browser, then fill in
the information below. You may pay by check, money order, or credit card.
Mail the completed form to:
Southeastern Cave Conservancy
PO Box
71857
Chattanooga TN 37407-0857
423.867.2881 (Fax)
|
YES! I would like to join the Southeastern Cave
Conservancy and help buy, manage, and protect caves. |
| Please provide your contact information: |
| Name |
|
| Street |
|
| City |
|
| State |
|
| Zip Code |
|
| Telephone |
|
| EMail |
|
|
Chose either Regular or Sustaining
Membership: |
|
Regular Membership |
Annual Dues ___ $25 |
Additional Donation $ _______ |
| Regular membership is $25 per
year. Dues expire on September 30 of each year. Please enclose a check or money
order payable to Southeastern Cave Conservancy, or charge you dues using
the credit card section below |
|
Sustaining Membership - monthly or quarterly
contribution via debit or credit card
Please choose a
Monthly or Quarterly contribution amount: |
Monthly
Amount: |
___ $25 |
___ $20 |
___ $15 |
___ $10 |
Other
$
_______ |
Quarterly
Amount |
___ $100 |
___ $75 |
___ $50 |
___ $25 |
Other
$ _______ |
| Please specify the duration and starting date for your
contributions: |
Duration:
|
______
Until
Canceled
|
______
Twelve
Months
|
______
Six Months
|
___________ Other
|
Month to Begin: |
_____________________, __________ |
 ,  ,  , 
|
| Please fill in your credit card information: Be sure to
write your name exactly as imprinted on the card and to provide
your phone number above in case we need to contact you to resolve any
problems. |
Card Type: |
____Visa
|
___MasterCard |
___AmEx
|
___
Discover |
Card Number: |
|
Name on Card |
__________________________________ (as imprinted
on card) |
| Expiration Date: |
__________________________________ (as imprinted
on card) |
| Sustaining memberships totaling $120 or more per year and one-time
donations of $250 or more are recognized with an SCCI logo shirt. Please
specify your desired shirt size: |
| Shirt
Size: |
_____________________ |
To pay by credit card, please sign and date this form as indicated
below:
I hereby authorize the Southeastern Cave Conservancy, Inc. to charge my
account in the amount and for the duration indicated above. I understand
that I may terminate my sustaining membership at any time by contacting
the SCCi.
Signature: ________________________________________
Date:
_________________ |
