Annual Membership Dues
Regular Member $25
Senior and Disabled $10

Amount Enclosed ___$10  ___$25  ___$___ Gift
___ Cash  ___ Check

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.