MEMBERSHIP FORM
Lopez Community Land Trust

I would like to become a member of LCLT at the following level:

______ $10-$49	Friend	______ $500-$999	Sustainer
______ $50-$99	Supporter 	______ $1000-$4999	Patron
______ $100-$499 Contributor	______ $5000 +	Benefactor

______ I will be sending a matching gift from my employer: __________________________
______ I would like to make a monthly pledge of $_____________.
______ Please send me/us a monthly pledge reminder.

Credit Card Donations:
I would like to put the donation on VISA/MasterCard.
Name on card: __________________________________________________________

Card #: _________________________________________Expiration Date: _________(mm/yy)

Signature: ______________________________________________________________

Gift Amount:   ________________________________________

Donation Details:
How would you like your donation or tribute to be acknowledged in printed materials?

__________________________________________________   ______Do not use my name. 

Please send me LCLT’s newsletters via   ______Email   or   ______USPS mail.

______ Please send me a receipt. 

The Lopez Community Land Trust is a 501(c)3 organization. Federal Tax ID #: 91-1469975

My contact information:

Name:__________________________________________________

Street:________________________________________________________________________

City:_____________________________________  State:________ Zip: __________________

Email:________________________________________________ Phone:__________________

Please return to:
Lopez Community Land Trust, P.O. Box 25, Lopez Island, WA, 98261
Phone: (360)468-3723  Fax: (360) 468-3724  Email: LCLT@rockisland.com