The Wallace House and Old Dutch Parsonage Association

Supporter Levels:

Silver: $50.00
Gold: $75.00
Diamond: $100.00
Patron: $200.00
Benefactor: $500.00

NAME:____________________________________________________________________________________________


STREET ADDRESS:________________________________________________________________________________


CITY:_______________________________________________STATE:_____________________________ZIP:_______


EMAIL:____________________________________________________________________________________________

My $________check for membership is enclosed. (Membership received after July 4th of a year will be credited to the end of the following calendar year.)

[   ]   I am contributing an additional $__________to support the work of the Wallace House and Old Dutch Parsonage Association in preserving the continuing message of these special sites.

Thank you for your generosity.

Please print this form, fill it in, and mail it with your membership dues (and any additional contribution) to the address below.

The Association is a Federal 501(c)(3) corporation and your contribution is tax deductible to the fullest extent permitted under the law.