Membership is for a calendar year. Membership and contributions are tax deductible.

Name _____________________________________________________

Address ___________________________________________________

City ________________________State _______Zip ________________

Telephone (day)__________________(evening)____________________

Fax_________________ Email__________________________________

___I (and/or my spouse) work for a matching-gift company

___Signed matching form enclosed

___Matching form will be filed

I am applying for the following membership option:

___George Watts Hill Leadership Circle $1000

___Sustainer $500

___Patron $250

___Friend $100

___Contributor $75

___Family $50

___Individual $25

I would like to contribute to Preservation Durham

___Endangered Properties Fund

      Amount_____________

___George & Mary Pyne Endowment Fund

      Amount_____________

___Enclosed is my check for $__________, payable to HPSD

___Charge to ___MasterCard ___Visa

Account #____________________________________Expiration date_________

Signature_____________________________

Please print this form, fill it in, and return by mail to: Preservation Durham, PO Box 25411, Durham NC 27702 or fax it with credit card payment only to (919)-682-3007. Thank you! October 2006