Azalea Charities Business/Community Membership

Registration Form
(please print this form, fill in the required info and return with your contribution)

( ) Yes, I/we would like to become a member of Azalea Charities, Inc.

___ Community Member ($100 annually)
___ Business Member ($150 annually recommended)

Enclosed is a contribution of $ _____________ Check #___________ Check date:_______________

( ) Yes, please keep us on the annual membership mailing list.

Make checks payable to: Azalea Charities, Inc.

Mail to:
Azalea Charities, Inc.
P.O. Box 579
Dumfries, VA 22026

EIN No.54-1973354 -501(c)3

All contributions of $250 or more will be acknowledged.

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Name

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Address

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City/State/Zip

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Phone (optional)

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Email (optional)