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I wish to join the DuBois Family Association in the membership level listed below. -------------------- Individual, one year $20           Individual, 3 yr $50 Household (2 adults),1 yr $30   Household ,2 yr $50 Family(2 adults,3 child)1 yr $60 Contributor,1yr $50 Donor, one year $100               Patron, 1 year $500                                             *Other Contributions:     (enter dollar amount)    General Fund:$      Fort Fund:$  Endowment Fund:$ ______________________ total Contributions :$ total Dues :$  GRAND TOTAL :$

NAME: ADDRESS:                         CITY:                Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin WyomingZIP:    Phone#       email:      __________________________ Signature   Please make checks payable to: DuBois Family Association Inc. (A not for profit corporation. Donations are tax deductible)