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Address: _________________________________________________________________

City/State/Zip: ___________________________________________________________

Phone: __________________________________________________________________

E-mail: ___________________________________________________________________

Membership Dues: ($20 per household or business) $________________ enclosed

Special Gift: $ ___________________

Please make your check payable to "Friends of Rocheport Society"

Mail to: Friends of Rocheport Society                  How would you like to receive information from FOR?

P.O. Box 122                                                         _____ E-mail

Rocheport, MO 65279                                          _____ U.S. Postal Service

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