Healing Racism in Anchorage Membership Form

Name:__________________________________________________________________

Organization (Optional):___________________________________________________

Mailing

Address:________________________________________________________________

Phone/FAX/E-mail:_______________________________________________________

___Student or Senior ($7)

___Regular: $20 - $99

___Contributor: ($100 - $249)

___Supporter: ($250 - $499)

Please make checks payabe to

Healing Racism in Anchorage and mail to

PO Box 92086, Anchorage, Alaska 99509-2086.

(If you wish to pay by Credit Card,

please use the Pay Pal button on the Join Us page).

Thank you for becoming a Member!

___Sustainer: ($500 - $999)

___Benefactor: ($1000 - $2499)

___Healer: $2500 - Above)

Please Print Form , Fill in and Mail!