Please print this form and mail to:

Leavenworth Main Street Program, Inc.
P.O. Box 243
Leavenworth, KS 66048

NAME: __________________________________________________________

BUSINESS NAME: ________________________________________________

ADDRESS: _______________________________________________________

CITY: ___________________________________________________________

STATE: ______________________________________ ZIP ________________

PHONE NUMBER: (______)_____________________

MEMBERSHIP: $250.00

CONTRIBUTION: ____$25.00 ____ $50.00 ____ $75.00 ____ $100.00 ______ OTHER AMOUNT

Make checks payable to:
Leavenworth Main Street Program, Inc.