Opacum Land Trust Membership Form

Opacum Land Trust Gift Membership

I would like to give a gift of conservation at the following level:

Membership Categories: Please select your membership gift:	Donor Categories: If you would like to make an additional donation:
_____ One Year, $25	_____Land Regent, $1000 or more
_____ Two Years, $40	_____Land Guardian, $500
_____ Three Years, $50	_____Land Conservator, $250
_____ Senior annual, (60+), $20	_____Land Preserver, $100
	_____Land Protector, $50
	_____Land Steward, $___________

OLT is a 501(c)(3) non-profit organization, all contributions are tax deductible.

This gift is for:

Recipient's Name:_____________________________________________

Address:____________________________________________

_____________________________________________

City, State, Zip:________________________________________

E-mail:______________________________________________

Phone:______________________________________________

This gift is from:

Giver's Name:_____________________________________________

Address:____________________________________________

_____________________________________________

City, State, Zip:________________________________________

E-mail:______________________________________________

Phone:______________________________________________

Please make checks payable to Opacum Land Trust, and send it with the gift membership form to:

Opacum Land Trust
P.O. Box 233
Sturbridge, MA 01566

Thank You For Your Gift!