Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: _____________________________________________ State: ________________________
Phone: ________________________ Other Phone: _______________________
E-Mail: _____________________________________________
New Member: _______ Renew Membership: _______
Annual Memberships:
_____ Individual / $10.00 _____ Family / $25.00
_____ Sponsor / $50.00 _____ Patron / $100.00 _____ Lifetime / $1,000.00
I would like to help:
Refreshment _____
Book Sale _____
Decorations _____
Programs _____
Anything Needed _____
Please print this form and mail along with your Tax Deductible check to:
Independence Public Library
220 E. Maple Street
Independence, KS 67301
Thank You!