Van Riper House
PO Box 110031
Nutley NJ 07110
I (we) _____________________________________________ (print name)
Apply for membership in
The
Van Riper House Restoration Trust
for the year _______ in the following category:
| Annual Student | $5.00 | ____ |
| Annual Individual | $10.00 | ____ |
| Annual Couple | $15.00 | ____ |
| Annual Patron (business) | $50.00 | ____ |
| Individual Lifetime Memberhsip | $150.00 | ____ |
| Couple Lifetime Membership | $250.00 | ____ |
| Business Life Membership | $500.00 |
_____
|
| Additional Donation | _______ | _____ |
Signed _____________________________________________
Print Name _________________________________________
email (optional) __________________________________
Address ____________________________________________
City _____________________ STATE _____ ZIP __________
Phone ______________________________________
I WISH TO VOLUNTEER MY SERVICES ( ___ )
Send check and application to:
Van Riper House, PO
Box 110031, Nutley, NJ 07110