Membership Information

Membership Application 
French Azilum, Inc.
469 Queens Road
Towanda PA 18848
TheFrenchAzilum@gmail.com
570-265-3376 


The French Azilum, Inc. 

MEMBERSHIP APPLICATION



Thank you for wanting to be a Member of The French Azilum. Members are our greatest assets, and we welcome you happily to our expanding group of friends, supporters and volunteers.

Please print, then fill out this application and return it along with your payment to:


The French Azilum

469 Queens Road

Towanda, PA 18848


You will receive a notification by mail of our receipt of your membership donation, which may be used for tax purposes.

Thank you very much again, and we look forward to seeing you at the site!

_________________________________________________


Name:_________________________________________


Address:________________________________________


               ________________________________________


Email & Phone:___________________________________


Membership Level (tick appropriate one):


______Individual ($25)         _______Family ($40)   


______Supporter ($75)          _______Contributor ($100+)


______Sustainer ($200+)     _______Benefactor ($500+)


 _______Corporate ($1000+)


IF YOU WOULD LIKE TO VOLUNTEER AT THE SITE, PLEASE INDICATE BELOW. THANK YOU!


YES, I would like to help out, especially with: 


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