Name____________________________________________________________________________
Address_______________________________City______________State_______Zip____________
Union /Organization________________________________________________________________
Phone_________________________ -Fax__________________________________
e-mail ____________________________
Individual Union Organization
( ) Senior/Student $10.00 ( ) $50 x 3 years = $150
( ) General/Individual $20.00 ( ) $100 x 3 years = $300
( ) Supporting/Couple $25.00 ( ) $200 x 3 years = $600
( ) Sustaining/Family $30.00 ( ) $500 x 3 years = $1,500
( ) Benefactor $50.00 ( ) $1,000 x 3 years = $3,000
( ) Other - Please specify amount ______________
Please make checks payable to: American Labor Museum and
send with this completed form to : Botto House National Landmark,
83 Norwood Street, Haledon, New Jersey 07508
Tel.: 973-595-7953 Fax: 973-595-7291
e-mail: labormuseum@aol.com