Annual Membership Dues
Regular Member $25
Senior and Disabled $10
|
Amount Enclosed ___$10 ___$25
___$___ Gift |
Date | |||||
| First Name | MI | Last Name | ||||
|
Street Address |
||||||
| City, State | Zip | |||||
|
Home Phone |
Precinct | School District | ||||
| Occupation | Email Address | |||||
|
Signature |
||||||
| Dues, contributions, or gifts to HTA are not deductible as charitable contributions for Federal income tax purposes. |