Enclosed is my membership support of:
_____ Chestnut Leaf - $5,000
_____ Gold Leaf - $1,000
_____ Silver Leaf - $500
_____ Bronze Leaf - $250
_____ Green Leaf - $100
_____ Regular - $40
_____ Student - $15
_____ Other $ _________
Special gift to State Chapter
$ _______ (Circle one) AL CT GA IN KY MA MD ME NC/SC NY OH PA TN
$ ____________ TOTAL AMOUNT ENCLOSED
Membership includes a subscription to
The Bark
and
The Journal of The American Chestnut
Foundation
and enrollment in a
State Chapter
if one is
chartered in your state.
TACF is a 501(c)(3) not-for-profit membership corporation. Donations are tax deductible to the extent allowed by law
NAME_____________________________________________________________ ADDRESS__________________________________________________________ CITY_____________________________________ STATE______ ZIP__________ PHONE__________________________EMAIL_____________________________
□This is a gift membership from ______________________________________
Address _______________________________________________________
□Check Enclosed (make payable to The American Chestnut Foundation)
□ Credit Card VISA MC _ ___ - ____ -____ - ____ Exp. Date ____/____/____
Name on Card ______________________________________________________
Credit Card Billing Address if different from Above: NAME_____________________________________________________________ ADDRESS__________________________________________________________ CITY_____________________________________ STATE______ ZIP__________ PHONE__________________________EMAIL_____________________________
SIGNATURE _______________________________________________________ Date_____________
The American Chestnut Foundation
469 Main St., Suite 1, PO BOX 4044, Bennington, VT 05201
802-447-0110 www.acf.org chestnut@acf.org
