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Your membership is tax deductible.
Please print this form and complete it.

The membership is available at the following levels:

Please mark one.

[ ] Student/Senior $15.00

[ ] Member (Family) $20.00

[ ] Supporting Member $50.00

[ ] Sponsor $100.00

[ ] Patron $200.00

[ ] Jack London Fellow $500.00

[ ] Life Time Member $1000.00

Name________________________________________

Address______________________________________

City_________________State____Zip Code_________

Country__________________

Phone _____-_____-_______   E-mail _____________________

Payments may be made by check, U.S. Postal money order, international money order, American Express, MasterCard, or Visa. Please make checks or money orders payable to Jack London Foundation, Inc.  There will be a $2.00 Service Charge for use of Credit Cards.

[ ] American Express [ ] MasterCard [ ] Visa

Number____________________ Exp. Date___________  CVS ________

Name on Card________________________

Signature____________________________

Mail application to:
Jack London Foundation, Inc.
P.O. Box 337
Glen Ellen, CA. 95442