Thoreau: Join the Thoreau Society by Mail

Name: Mr./Ms./Dr. ____________________________________________________________________

Address: ____________________________________________________________________________

City: ___________________________ State: _____ Zip Code: ___________ Country:_____________

Home Phone: (____)_____-________ Work Phone: (____)_____-_______Fax: (____)_____-________

E-Mail: __________________________________ Website: ____________________________________

Membership Levels: (check one)

[ ] Individual (US/Canada/Mexico)	$45
[ ] Individual (Overseas)	$55
[ ] Family (US/Canada/Mexico)	$60
[ ] Family (Overseas)	$70
[ ] Student (US/Canada/Mexico)	$25
[ ] Student (Overseas)	$35
[ ] Sustaining	$80
[ ] Library Subscription (US/Canada/Mexico)	$75
[ ] Library Subscription (Overseas)	$90
High School Memberships
[ ] High School (US/Canada/Mexico)	$60
[ ] High School (Overseas)	$70

Membership Donor Circles:
(includes a 1-year membership)

[ ] Maine Woods	$100
[ ] Cape Cod	$250
[ ] Concord & Merrimack	$500
[ ] Walden	$1000
[ ] Life Membership	$1250
If this is a Gift Membership, please include your name and address in this box. _________________________________ _________________________________ Check here if you would like to make an additional donation to the Friends of Walden Pond, which goes directly to preserve and maintain Walden Pond State Reservation. [ ] $10 [ ] $20 [ ] $50 [ ] Other $_____

Method of Payment: (Please fill in completely; US $ Dollars only)

[ ] Check or Money Order
[ ] Visa
[ ] Master Card
[ ] American Express
[ ] Discover

Credit Card Information
Card Number:__________________________________________________

Expiration Date:________________________________________________

Signature:_____________________________________________________

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