R.E.S.C.U.E. Membership Form

Please check your level of membership and mail your check,
made payable to the chapter of your choice, with this form.

____ $5.00 Newsletter Membership *
____ $100.00 Patron
____ $10.00 Individual Membership ____ $1,000.00  Life Member
____ $20.00 Family Membership ____ $50.00 Sustaining Membership
____ $_________ Extra donation for the Benjamin Stone Scholarship Fund

PLEASE PROVIDE ALL THE FOLLOWING INFORMATION:
(We never sell or exchange our mailing list to any other organizations.)

Name:  _______________________________________________________________________________

Address:  ____________________________________________________________________________

City, State, Zip:  ______________________________________________________________________

Phone:  _____________________________________________________________________________

E-mail Address________________________________________________________________________


Please select one of R.E.S.C.U.E.'s Chapters:


______ Wayne/Susquehanna R.E.S.C.U.E.    P.O. Box 67    Forest City, PA  18421

______ North Branch Concerned Citizens    RR5 Box 184    Montrose, PA  18801

Thank you.

Website:  www.rescue-nepa.org      Email: rescuenepa@gmail.com