Application

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