CERTAIN MEMBERSHIP FORM

Name: _______________________________________________________________

Address: _________________________________________________

Address: _________________________________________________

City: _______________________________     State/Province: ________

Zip/Postal Code: ______________

Telephone: (          ) _________________________

Fax: (          ) _________________________

E-mail: (          ) ______________________________________________________


Donation Amount:  __  $30.00        __  $50.00        __  Other  ($              )


T-Shirt size:   Medium:______        Large:______        X-Large:_____


Thanks for helping fight anti-Indian racism and attacks on our sacred treaty rights. The CERTAIN Council Circle.

CERTAIN - Coalition to End Racial Targeting of American Indian Nations
3400 E. Speedway Blvd.
Suite 118-259
Tucson AZ 85716
(520) 370-7136