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Membership Application for Friends of Quantrek

Quantrek is a 501(c)3 and a 509(a) tax exempt publically supported non-profit organization. We will confirm your membership status via email.

Membership amount and levels:

         Amount / Level

To become a Friend of Quantrek, please complete the following membership form and pay online or print out the form and mail it along with your check to:

Dr. Edgar Mitchell

Quantrek, Inc

PO Box 540037

Lake Worth, FL 33454-0037

 

Your membership payment is secured by:
Solution Graphics

 

I am interested in making a restricted gift to the Frontier Science Endowment Fund. Please contact me or send additional information.

I would like to make an unrestricted gift to support the work of Quantrek. (Enter the amount you wish to pledge below).

Please send me an invoice for the amount I have pledged to contribute

 Amount pledged:               

       Prefix: 

*First Name:

      Middle:

*Last Name: 

       Suffix:

 *Address1:

  Address2:

        City:     

State / Province:   

     *Postal code:  

           Country: 

*Email Address:   

 Day Telephone:  

 

 Evening phone:  

 

Thank you for your generous support.