| Name: | _________________________________ |
| Address: |
_________________________________
_________________________________ _________________,______ _________ |
| Phone: | (______) ______ - __________ |
| E-Mail: | _________________________________ |
|
[] New Membership
[] Gift Membership [] Renewal Membership (Member ID# _____________) |
|
| $25 Basic Membership | 6 issues of Tide Magazine, window decal, bumper sticker and patch. |
| $100 Membership | CCA Print, 6 issues of Tide Magazine, window decal, bumper sticker and patch. |
| $200 Sponsor | Bronze lapel pin, CCAPrint and member gifts. |
| $500 Patron | Silver lapel pin, CCAPrint and member gifts. |
| $1000 Life Member | Gold lapel pin, CCAPrint and member gifts. (Payable in $250 installments) |
| $15 Associate Member | for each additional family member; all member privledges except extra copies of Tide. |
| $10 New Tide Membership | all individuals 17 and under receive member benefits and Rising Tide Magazine |
| $____ Donation | I would like to make an additional donation to CCA New Hampshire |
|
Send check or money order along with completed application to: CCA New Hampshire, PO Box 4372, Portsmouth, NH, 03801 |
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