I want to support the

Priestley-Forsyth Memorial Library

Name:__________________________________________

Address:_________________________________________

City: ___________________________________________

State: ______________________ Zip: _______________

Phone: ______________________________

Please check your prefered gift level:

I would like to become:

_____A Book Lover                                       $25-$50

_____A Series Fan                                        $50-$100

_____A Classic                                             $100-$250

_____A Poet                                                 $250-$500

_____A Novelist                                           $500-$1000

_____An Epic                                              $1000-$5000

_____A Pulitzer                                           $5000+

Payment Options:

_____I am enclosing payment

_____Please bill me quarterly

_____Direct Debit (you may arrange this through the library by requesting an authorization agreement)

Please mail this form with payment made payable to:

Priestley-Forsyth Memorial Library

100 King Street, Northumberland, PA

17857