Membership Form

Spring Village Association

New York Chapter

Member Information (please print or type)

Name

Mailing address

City

State

ZIP Code

Telephone (home)

Telephone (business)

Fax

E-Mail

Annual Membership Fee $25.00 US

I ____________________ pledge a total of $____________, to be paid:
____ yearly as my annual membership fee to the Spring Village Association New York Chapter.

Additional Contribution

I ____________________ plan to make an additional contribution of $____________, in the form of:
____ cash ____ check____.

Gift will be matched by _________________________________ (company/family/foundation).
____ form enclosed ____ form will be forwarded

Acknowledgement Information

Please use the following name(s) in all acknowledgements:

____ I (we) wish to have our gift remain anonymous.

Signature(s)

Date

Please make checks, or other gifts payable to: Spring Village Association, New York Chapter.

Please print, sign and mail with your contributions to:

Spring Village Association

New York Chapter

1036 E 232nd St.

Bronx, New York, 10466