MEMBERSHIP  APPLICATION

   NAME_____________________________
   
   ADDRESS__________________________
   
   CITY______________________________
   
   STATE__________________ZIP________

  PHONE_____________________________

  email________________________________

  Type of Membership (check):
   __prisoner $2.00 or five stamps
             inmate #____________
  __individual $10.00   
  __family member $20.00
  --sustaining  $50.00      __life $100.00
  __other _____________

How did you hear about us?

__friend               __family member
__prisoner    __newspaper   __search the web
__flyer or brochure      __other

                          NEVADA  CURE
                                PO Box 467
                          Yerington, NV 89447