First Name * Last Name* Email Address * Alternate email address if any Phone Number Address City State Zip Best way to contact me Phone E-mail   MEMBERSHIP LEVEL Basic $20 Contributor $50 Friend $75 Patron $100 Conservationist $150 Land Steward $200 Guardian $250 Other Enter desired membership amount * Additional contribution for the Land Acquisition Fund Additional contribution for the Whigville Preservation Fund Total Donation Corporate match I will send a corporate matching gift form Do you want to be on our email Volunteer List? Yes No Volunteer interest(s), Comments or Suggestions Payment Method * Paypal (Submit, then system automatically goes to Paypal. Complete the transaction.) To pay by check, Submit the form; then when system automatically goes to Paypal, just exit. Make check payable to THE BURLINGTON LAND TRUST, and send to BOX 1153, BURLINGTON, CT 06013.