Hersey Family Farm Phase 2

Name: ____________________________________________________

Address: ___________________________________________________

Phone: ___________________________

E-mail: ___________________________

Make checks payable to: ASLPT and mail to PO Box 2040, New London, NH 03257

Enclosed is my donation of:

___  $10,000 ( and above) Ausbon Sargent Society

___  $5,000 + Legacy Circle

___  $2,500 + Leadership Circle

___  $1,000 + Benefactor

___  $500 + Patron

___  $250 + Steward

___  $150 + Protector

___  $60 + Advocate

___  $________ Other

If you would like to join by writing a check just print out this page, filling in the information and make your check payable to: ASLPT

Mail to: ASLPT, PO Box 2040, New London, NH 03257