Name

Business/Organization

Address

City, State Zip

Phone

Fax

E-mail

Membership Types

Individual/Family ($10)

Junior (under 15) ($1)

Organization/Business ($25)

Lifetime Membership ($100)

Other/Honorary ($25+)

For questions and additional information, call (814) 944-2383
Make checks payable to: Clearfield Creek Watershed Association

Please mail this form along with your payment to the address indicated below or present it to the secretary at a Watershed Association meeting.

c/o Earl Smithmyer
216 Beldin Hollow Road
Ashville, PA 16613

Receipt
Membership Types

Individual/Family ($10) [  ] Junior ($1) [ ] Organization/Business ($25) [  ] Lifetime Membership ($100) [  ]
Other/Honorary ($     ) [  ]

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