MEMBERSHIP APPLICATION	Endless Mountains         Heritage Region, Inc.     1 Washington Street       Towanda, Pennsylvania
Yearly Memberships:                           _____ Individual       $      35                           _____ Family            $      50	18848                             Phone: 570-265-1528  Email: emhr@epix.net www.endlessmountainsheritage.org

                                          Non-Profit and For-Profit:
                                          (varies depending on the # of full-time employees or equivalencies)
                          _____ 1 - 10              $     100
                          _____ 11 - 50            $     150
                          _____ 51 - 250          $     250
                          _____ 251 +              $     500

                          _____ Amount of Additional Contribution

Special Donations by Individuals/Businesses:

                          _____ Golden Oak       $ 10,000
                          _____ Silver Maple      $   5,000
                          _____ Copper Beech    $   1,000

Please place an "X" next to your choice and make checks payable to EMHR, Inc. Funds will be
used to support programs and activities.

Name_____________________________________

Address____________________________________ Phone#_________________________

Signature ___________________________________ Date ___________________________

"The Possibilities Are Endless"