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.