Tewaukon National Wildlife Refuge
Mountain-Prairie Region
~ Join Us! ~

Complete this membership form and Mail to:
Prairie Pothole Partners
c/o Tewaukon Wildlife Refuge
9754 143 1/2 Avenue SE
Cayuga, ND 58013-9784

Your Name: ________________________________________
Address: ___________________________________________
City: ______________________________________________
State/Prov.:_____________ ZIP/Postal Code: ______________
Phone: ____________________________________________
Fax: ________________________________
Email: _______________________________

Enclosed is a: Check _______Money Order _______
Total Amount: ____________
Membership: For self _______
Gift Membership to: __________________________
Full Address: _______________________________

Student and Senior $5
Individual $10
Family $15
Business & Clubs $50
Lifetime Individual $100
Lifetime Family $150
Other (Donations are tax-deductible)______________

Make checks payable to: Prairie Pothole Partners

Last updated: March 10, 2011