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
