Member Name
Member Name (as you wish it to appear on your membership):

Member Mailing Address:   

              Street Address:

              Town:                                                                    State:                     Zip Code:

               Phone Number:

               E-mail Address: 

Amount Enclosed:      

        __ Basic (Individual) Membership: $25

        __ Joint Stewards (Family Membership - two individuals at the same address): $45

        __ Senior (65 and older): $10

        __ Student (18 and younger): $10

DONOR Categories:     

        __  Land Protector:          $  100

        __  Land Caretaker:         $  250

        __  Land Conservator:      $  500

        __  Land Granter:            $1,000

        __  Keeper of the Land:    $2,500

Gift in Memory

 __ A gift in memory/honor of a friend or relative

Name of person to be honored:

Name and address of person to be notified of gift:

Please make checks payable to: The New Roxbury Land Trust, Inc.  Contributions are tax deductible as provided by law. Your membership is valid until the Spring of the following year.

MAIL FORM AND CHECK TO:  The New Roxbury Land Trust, Inc., PO Box 98, Woodstock, CT 06281.

For more information, contact: 

Valerie Ietto, PO Box 98, Woodstock, CT 06281.