55 Old Bedford Road
  Concord, MA 01742
  info@thoreausociety.org


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) $40
     [  ] Individual (Overseas) $50
[  ] Family (US/Canada/Mexico) $55
     [  ] Family (Overseas) $65
[  ] Student (US/Canada/Mexico) $20
     [  ] Student (Overseas) $30
[  ] Sustaining $75
[  ] Library Subscription (US/Canada/Mexico) $60
     [  ] Library Subscription (Overseas) $75
   Membership Donor Circles:
(includes a 1-year membership)
 
[  ] Maine Woods $100
[  ] Cape Cod $250
[  ] Concord & Merrimack $500
[  ] Walden $1000
[  ] Life Membership (as of 1/1/2007)
 $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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