Please print and complete this form, then bring or mail it to CNC
at the above address.

Name_____________________________________________________________________

Address___________________________________________________________________

City_______________________________ State___________

Zip___________________

Phone_____________________________________________________

E-Mail_____________________________________________________

Is this a Gift? 

If so, list Recipient name ___________________________________________________

Recipient address ___________________________________________________________

Recipient city, state and zip ______________________________________________________

Date you would like Recipient to receive materials ____________________________________

** Please note level of Membership: Puppy $25, Alpha $50, Pack $100 or Sustainer $500 **

Amount of Payment__________________________________________

Method of Payment:

_____  Check (payable to CNC)

_____  Charge to Visa, Mastercard or American Express (please circle one)

Account #_______________________________ Exp. Date ______

Signature_______________________________________________________

For more information, call Tish Gailmard (Wildlife
Curator) at 423-821-1160 ext. 103