Membership Dues and Donations Form

Name(s): ________________________________________________________________________

Street Address: ___________________________________________________________________

City, State, ZIP: ________________________________________, ___________, ______________

Country:_________________________________________

Phone: ___________________________________ FAX:__________________________________

E-Mail:  _________________________________________________________________________

May we send the newsletter to you by using this email address?  _____________________

WALF Membership Dues   (Includes subscription to The Leavitt Letter): $25.00 for one household:

Amount included in the Dues Payment: $___________________

Donations to support WALF Operations   (Board of Directors approved expenditures)

Amount included in the Donation Payment: $___________________

TOTAL AMOUNT SUBMITTED: $___________________

(Please pay by check or money order in U.S. currency to: Western Association of Leavitt Families)

COMMENTS:

(Perhaps you could mention where you tie into the family of Leavitt descendants)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Please print this form and return it with your check to:

WALF, P.O. Box 130, Cedar City, Utah 84720

Thanks Soooo much for your help and participation in this great family enterprise!!