Friends of Rocheport

Name:   __________________________________________________________________

Address:  _________________________________________________________________

City/State/Zip:  ___________________________________________________________

Phone:  __________________________________________________________________

E-mail:  ___________________________________________________________________

Membership Dues:  ($20 per household or business)  $________________ enclosed

Special Gift:  $ ___________________

Please make your check payable to "Friends of Rocheport Society"

Mail to:     Friends of Rocheport Society

                P.O. Box 122

               Rocheport, MO  65279