Van Riper House
Historic Restoration
Trust
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 Membership | $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