Broads Membership/Donation Form

Type of Donation:

Basic Broad $35           $50 Rockin' Broad     $75 Wild Broad   $100+ Outrageous Broad     $1,000+ Bedrock Broad  
Budget Broad (less than $35)                                                                                         Total Personal Membership Donation $ ______________
Gift Membership ($35 minimum)    
Honorary/Memorial Gift ($35 minimum)                                                 Total Gift Membership or Honorary/Memorial Donation $______________

Special donation or additional donation $50 $100 $500
Other                                                                                                                                                Total Additional Donation $______________

$
Total Amount:

 
Dedication:
To give a gift membership or to make an honorary/memorial donation, please enter the person's name and address below. We will be sure to send them or their loved ones a note letting them know that you gave this wonderful gift. Gift Membership Honorary/Memorial Donation
Name:
Address:
City: State: Zip:
Phone: Email:

* For donations of $100 or more, we'll send you your choice of a Richard Winship fine art print or a Broads ceramic mug. (View these items at the bottom of the linked page).

Please send me a Richard Winship print Please send me a Broads ceramic mug
Send the gift to gift member No gift is necessary

If you would like to purchase T-shirts or other merchandise for yourself or to include with a gift membership, please go to our shopping cart for options. You can make a note on this form as to what you'd like and include the cost of the item(s) in the total. Questions? Contact Joyce at 970-385-9577 or membership@greatoldbroads.org.

Contact/Payment Information: My Check is enclosed Please bill my credit card (listed below)
Name:
Address:
City: State: Zip:
Phone: Email:
Credit Card Information:
Today's Date: Card Type (circle one): MC --- VISA ----AmEx --- Disc Card Number:
Exp. Date: Security Code: Signature:

Please do not share or trade my name with other like-minded organizations.
Mail payment to: Great Old Broads for Wilderness, PO Box 2924, Durango, CO 81302