Membership Application for
		Friends of the Jennie Wade
Name:_____________________  Individual [  ]  Family [  ] Corporate [  ]  Community [  ]  Organization [  ]
Address:____________________________  City:__________ State:_______Zipcode:_______ County:_________
Phone:_____________Fax:________________Email:____________ URL:_________________________________
Please complete one of the choices below:
	I/ we would like to take an active part in the continuing development of the Jennie Wade Media Center. My/ our talents or interest are as follows:_____________________________________________________________ I/ we would like to support this project through our membership and the following donation: _______________________ I/ we would like to actively support this project through both areas and have listed both above.________
Mail or drop off your membership information and donation (payable to Friends of the Jennie Wade) to:
First State Bank, Attention: Dee Hayes 101  Main Street  Ripley, Ohio 45167
A list of sponsors, corporate, community, organizational, family and individual will be posted regularly on the Internet site. This is a community supported project and each member is a critical part of this project. Member's input and participation in the project is encouraged but not required.