YES!  Sign us up for membership at Crowe's Nest Farm!

Please Print Clearly:
Last Name:_______________________________________________________________________

First Name:  Mr./Mrs./Ms./Dr.________________________________________________________

Address:_________________________________________________________________________

City, State, Zip:____________________________________________________________________

Home Phone:_______________________________ Work Phone:___________________________

Fax:______________________________________ Email:_________________________________

Membership Level
(check appropriate circles)

• Individual   $35
• Family/Sower/Plower   $100
• Harvester    $250
• Patron   $500
• Charter   $1000
• Benefactor   $2500
• Gold   $5000
• My employer will match my gift.  (Please submit the appropriate form to you employer.)

Your organization's name:_____________________________________________

• This is a gift membership from:
  
   ______________________________________________________________

Phone:__________________________         Today's Date:__________________

Please return with payment (personal check, cashiers check, or money order) to: