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CAVALIER HEALTH FOUNDATION MEMBERSHIP
APPLICATION
Dues for membership year
January 1 – December 31, 2007
Please print clearly
________________________________ ____________________
___
Last name First
name Initial
__________________________________________________________________
(Address, City, State, Zip, Country
__________________________________________________________________
__________________________________________________________________
(Phone, Email, Fax)
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Membership categories and dues |
$
Amount enclosed |
| |
| [ ]
Sustaining |
$25.00-$99.00 |
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| [ ]
Supporting |
$100.00-$249.00 |
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| [ ]
Sponsor |
$250.00-$499.00 |
|
| [ ]
Patron |
$500.00-$999.00 |
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| [ ]
Friend |
$1000.00-$2499.00 |
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| [ ]
Leader |
$2500.00-$4999.00 |
|
| [ ]
Founder |
$5000.00 and up |
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| [ ]
Corporator* |
$100.00 and up |
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| |
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*Elected position. Please attach
a one-page personal resume |
Donation:
[ ] in honor of
________________________________ $_________________
[ ] in memory
of_______________________________ $_________________
TOTAL AMOUNT ENCLOSED $__________________
The Foundation is a Section
501(c)(3) organization.
Dues and donations are tax deductible to the extent permitted by
law.
Make checks
payable in U.S. currency to: Cavalier Health Foundation.
Return to:
Cavalier Health Foundation
C/O Betsey Lynch
6230 Duffy Road
Delaware, OH 43015 |