--------------------------------------------------------------------------------------------

     Name: _______________________________________         
             (Please Print Your Full Name)                    

  Address: _______________________________________ Telephone: (Home)     (___) ________


     City: _________________State:_____Zip:_______ Telephone: (Business) (___) ________

    e-mail:_______________________________________

               Place a check mark next to your Membership Category...

                                                  Single Membership  $20.00  ______  
 
                                                Family Membership  $30.00  ______

                                                      
     I wish to make an additional donation to the ALCWRT in the amount of $______

                                                                        Total Amount Enclosed: $______                       
                                             
Please return this form with your payment (checks payable to ALCWRT) to:

       ALCWRT
       c/o Worley Smith
       10035 Orchard Ridge Court
       Holly, MI  48442

--------------------------------------------------------------------------------------------