Member Application – Van Riper House Restoration Trust
Van Riper House Historic Restoration Trust
I (we) ___________________________________________ (print name)
Apply for membership in
The Van Riper House Restoration Trust for the year _______ in the following category:
| Annual Student | $5.00 | ____ |
| Annual Individual | $10.00 | ____ |
| Annual Couple | $15.00 | ____ |
| Annual Patron (business) | $50.00 | ____ |
| Individual Lifetime Membership | $150.00 | ____ |
| Couple Lifetime Membership | $250.00 | ____ |
| Business Life Membership | $500.00 | _____ |
| Additional Donation | _______ | _____ |
Signed _______________________________________
Print Name ___________________________________
email (optional) ________________________________
Address ______________________________________
City _____________________ STATE _____
ZIP __________
Phone ______________________________________
I WISH TO VOLUNTEER MY SERVICES ( ___ )
Send check and application to:
Van Riper House, PO Box 110031, Nutley, NJ 07110
