NEW MEXICO CITIZENS FOR CLEAN AIR & WATER
MEMBERSHIP & DONATION MAILING FORM

Print this form, fill out, and mail to:
NMCCA&W
PO Box 5
Los Alamos, NM 87544

NAME(s):________________________ ___________________ ____ _______ .............(last).................(first)..........(mi).(title)

ADDRESS: _______________________________________________________ ..........(street, PO Box, or route) .

..........______________________________________________________ .

..........____________________________________..______.._________ .............(city).............................(state)...(zip)

PHONE:...._________________________________(optional) .

E-Mail:..._________________________________(optional) .

ENCLOSED:(mark as appropriate)

.........___$10 individual ___$20 family ___$5 student .

....additional donation: $_______

Thanks. Your donation works to preserve the environment. How much is a blue sky worth? A clear stream? A cup of clean water?

-------WE DO NOT RELEASE OUR MEMBERSHIP LISTS TO ANYONE!--------