Please print this page and send your completed application to:

Panther Creek Valley Foundation
No.9 Mine and Museum
9 Dock Street
P.O. Box 287
Lansford, Pa. 18232-0287

Memberships run from 6/1 to 6/1 of each year.

Last Name:___________________

First Name:___________________

Middle Initial:______

Street Address:_______________
_____________________________

City:_________________________

State:________________________

Zip Code:____________

Telephone:___________________

Type Of Application

RENEWAL MEMBER _____

NEW MEMBERSHIP _____

DONATION _____

Membership Type Requested:____________

Amount Enclosed:______

TYPES OF MEMBERSHIPS

REGULAR > Has all rights and voting privleges / $10.00

CONTRIBUTING MEMBER REGULAR > Has an interest in the goals of the corporation but shall not have any voting rights / $5.00

FAMILY > Has an interest in the goals of the corporation but shall not have any voting rights / $7.50

CORPORATE MEMBERSHIPS
Silver > $100.00 to $500.00
Gold > $501.00 to $1,000.00
Platinum > $1,001.00 +

Thank you for your exceptional support of our organization. We NEED and APPRECIATE your help.