Athol Bird and Nature Club
                    Membership Application


                     PLEASE PRINT or TYPE

          Name ___________________________________________
          Address ________________________________________
          ________________________________________________
          ________________________________________________
          Home Phone _____________________________________
          Work Phone _____________________________________
          Email  _________________________________________

          [ ] Student     $  5.00
          [ ] Individual  $ 15.00
          [ ] Family      $ 25.00
          [ ] Inside  window decal $1.00
          [ ] Outside window decal $1.00
          [ ] Contributor $ 50.00 *
          [ ] Patron      $ 100.00 *
          [ ] Benefactor  $250.00 *
	[ ] Additional donation to the 
                Millers River Environmental Center (MREC) **
                Enter amount: $___________

	Please enter total amount enclosed: $_______________

	Please check one:
          [ ] New Member
          [ ] Renewal
          [ ] Former member
          [ ] Gift from ___________________________________
		Send gift card with your name?    [ ] Yes   [ ] No


        *  Includes an optional ABNC decal.
	    If desired, check one:  [ ] Inside  [ ] Outside

        ** Dues in excess of $10.00 and all donations to the MREC
             Fund are tax-deductible. 



          Make check payable to: Athol Bird and Nature Club
          Mail check and completed form to
             Athol Bird and Nature Club
             Millers River Environmental Center
             100 Main Street
             Athol MA 01331