Join The Canary Coalition

Please fill this page out, print it (press 'Ctrl' & 'P' at the same time),
and drop in the mail... Thank you for your support!

We are working to get this form to work online, soon.
In the meantime, you can send us an e-mail with your address and we will mail you an application.

Save us the stamp! Print this page out, mail it to us with your tax deductable donations to the address at the bottom of this page. Thank you for your support!

The Canary Coalition is your family, friends and neighbors getting together to do something about the poor quality of air we've been breathing in western North Carolina and the southern Appalachian region. Only with your help can we achieve this goal. Don't forget to tell your friends and family!

Please sign me up as a sponsor / member of The Canary Coalition!
All information provided will be kept confidential.

Name:

Organization (optional):

Title (optional):

Address:

City:

State / Zipcode:

E-Mail address (optional):

Web site or link (optional):

Daytime phone (optional):

Would you like to be listed in our Directory of Supporters?
Yes, please list my name.
Yes, please list my organization's name only.
Yes, please list my name, title and organization.
No thank you, I wish to remain anonymous.

Would you like to volunteer?
Yes, please have someone contact me at the phone number above!
I'm not sure about volunteering, but I am interested in getting involved!
No, not at this time.

We thank you for your generous donation!
Please select your donation and mail it to the adresss at the bottom of this page along with this form, thank you!
$5 - $25 join the ranks
$25 - $100 individual sponsor
$50 - $1,000 businesses and organizations
Other (any amount is welcome)

FREE, WITH YOUR $35 DONATION!
YOUR CHOICE OF A BEAUTIFUL 100% COTTON CANARY COALITION T-SHIRT OR CANARY COALITION BASEBALL CAP! WEAR IT PROUDLY, WHILE THEY LAST!

THANK YOU!
All donations are tax deductable.
We are a 501(c)3 non-profit organization.