| |  | Your Name: ____________________________________________________________________________ Address:_______________________________________________________________________________ City_____________________________State________Zip____________Country_______________________ Telephone__________________________________Email_________________________________________ ____$ 25.00 CHARTER MEMBERSHIP in the name above (or if you prefer) ___________Anonymous ____$ 25.00 IN MEMORY of ________________________________________________________ ____$ 25.00 IN HONOR of ___________________________________________________________ Notes: __________________________________________________________________________ 
________________________________________________________________________________ 
_______ Cash (via registered mail)     __________ Check      __________ Money Order 
Questions? Contact....Mr. Harvey Abrams, President, IISOH  --  HAbrams@iisoh.org | 
 All donations over $25.00 receive Lifetime recognition.
All donations over $250.00 will receive additional recognition such as 
engraved bricks, plaques, etc., in accordance with the approval of the Board of Directors.
| April 22, 2013 Revised December 25, 2013 Revised August 4, 2014 Revised November 1, 2015 iisoh040 |