Black Canyon Land Trust

1500 East Oak Grove,

Suite 201

Montrose, CO 81401

Voice: 970/252-1481

Fax: 970/252-7209

email BCLT

"Promoting & ensuring conservation of private lands in the Uncompahgre, North Fork, and Lower Gunnison Watersheds."

BCLT Mail-in / Drop-in / Fax-in Support Form

Yes! I want to support the Black Canyon Land Trust at the following level:

_______ Supporting ($25-$49)

_______ Sustaining ($50-$99)

_______ Visionary ($100-$249)

_______ Benefactor ($250-$499)

_______ Silver Club ($500-$999)

_______ Gold Club ($1000+)

Name: ___________________________________________________

Address: __________________________________________________

___________________________________________________________

Telephone: ________________________________________________

Email: _____________________________________________________

Black Canyon Land Trust may wish to publish an acknowledgement of our supporters (we will not include the amount of your contribution). If you would prefer that your name not be disclosed, please check here.

BCLT can now accept credit cards!

Please charge my credit card.

MC/Visa # _________________________________________________________

Expiration Date ____________________________________________________

Print Name on Card _________________________________________________

Signature __________________________________________________________

Grand Total $ _____________________________________________________

Or return with your check payable to "BCLT" by mail, fax, or in person to:

Black Canyon Land Trust (BCLT)

1500 East Oak Grove,

Suite 201

Montrose, CO 81401

phone: 970/252-1481

fax: 970/252-7209

Thank You for your support!

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