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Membership Form

Package Name	Amount	Quantity	Subtotal

Individual	$50.00		$0.00



Family/Dual	$75.00		$0.00



Contributing	$125.00		$0.00



Sustaining	$250.00		$0.00



Director's Circle	$500.00		$0.00



Regular Corporate	$100.00		$0.00



Supporting Corporate	$250.00		$0.00



Sustaining Corporate	$500.00		$0.00

The Millicent Club and Corporate Benefactor ($1,000 or more)

Amount:

Total:

$0.00

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