| ________ | Individual Membership ($50) | |
| ________ | Family Membership ($60) | |
| (two people at the same address) | ||
| ________ | Life Membership ($350 or more) | |
| ________ | Newsletter Only ($15) | |
| ________ | Gift to DPAL (tax deductible) |
| Name | ________________________________ |
| Address | ________________________________ |
| City/State/Zip | ________________________________ |
| Phone | ________________________________ |
| Email Address | ________________________________ |
| Amount Enclosed | $_______________ |