CUSH Membership Dues and/or Donations Form

Name_______________________________________________________________

 

Mailing Address _______________________________________________________

 

City__________________________________State_____________Zip____________

 

Phone_______________________________Email_____________________________

 

New Membership $25.00 per year …………………….Amount Enclosed  $_________

Renew Membership $25.00 per year …………………..Amount Enclosed  $_________

Donations of any amount are appreciated………………Amount Enclosed  $_________

                                Total Enclosed for Dues, Renewal, or Donation…… $_________

 

If your Donation is in Memory or Honor of someone please complete the following:

 

In Memory of: Name______________________________________________________

 

In Honor of: Name________________________________________________________