Huntsville Wildflower Society Membership Form

Name_______________________________      Home Phone______________________

Street/Apt # _________________________      Work Phone _______________________

City/State/Zip ________________________      Email ____________________________

Member:     New_____ Renewal_______

(Any Address, Phone or Email Changes?     Yes___ No___      Please Circle Changes Above)

Local Dues:     Individual $7.00 ____       Family $10.00 ____

State Dues:     Individual $8.00 ____       Family $12.00 ____      Total Enclosed ______

OK to Publish Address: Yes ___ No ____         OK to Publish Phone Number: Yes___ No ___

Signature ______________________________________      Date: ____________________

Mail to George Hanna, Treasurer

706 Sherwood Drive SE

Huntsville, AL 35802