HMWF Mail-In Membership and Donation Form

Instructions: 

Please fill out this form by typing the information into the boxes on your computer screen.

At the bottom of the form, when you're satisfied that all of the information you've entered is correct, please click the button that says "Submit."  Note:  you will not be sending any information away from your computer when you click "Submit," or otherwise revealing any information to anyone.

When you click "Submit," you will automatically be taken to a new page that summarizes all of the information you  entered on the form.  You will print that new page using your own printer and then mail that page to HMWF the old-fashioned way, with an envelope and a stamp.

You can therefore enter your credit card information on this form with complete confidence; neither your financial information nor any other information you type will leave your computer.

A.  Your contact information

Title (click on the drop-down arrow and select the appropriate title):    Mr. Mrs. Ms. Dr.    

First name:    Middle initial:     Last name:     Maiden name (if internee): 

Street address:     Apartment number (if any): 

City:     State:     Zip Code:     Country:  

Home phone:     Business phone:     Fax:     Cellphone: 

Email address:    

I prefer to receive HMWF communication by (please select one by clicking on the drop-down arrow) conventional (postal) mail email

Occupation: 

Names as they are to appear on the membership roster (if different from, or in addition to, name given above): 

1.   2. 3.

B.  Your relationship, if any, to the Heart Mountain Relocation Center and/or the incarceration of Japanese Americans in World War II

Are you a former internee at any of the WWII camps (click yes or no)?  Yes No  

If so, name of camp (please click in the box and enter camp name): 

Are you a descendant of internee at any of the WWII camps (click yes or no)?  Yes No  

If so, name of camp where relative was interned (please click in the box and enter camp name): 

Other comments, or other connections to any of the WWII camps? (click and type in the box below)

C.  Your Membership Category

(please click in the appropriate box and make a note of the applicable dues)

Corporate/business ($100)     Nonprofit organization ($50)   

Individual ($25)     Senior Citizen (age 60+) ($20)    Student (with valid i.d.) ($15)    Family (parents with children under 18) ($50)

Lifetime ($1000)

Your total membership dues:  $

D. Additional donation to the Heart Mountain, Wyoming Foundation

Would you care to make a tax-deductible donation to the Heart Mountain, Wyoming Foundation?  If so, enter the amount here:  $

E.  Payment Information

Please add up the sum of your membership dues and any additional donation you're making and enter that sum in this box:  $

Tell us how you'd like to pay by clicking on one of these choices:  I will write a check to HMWF and mail it along with this form. I will fill in the credit card information on this form and mail the form in.

If you'll be writing a check, please remember to make it payable to "Heart Mountain, Wyoming Foundation."

If you'd prefer to pay by credit card, tell us, by clicking on the drop-down arrow, whether you'll be using VISA or Mastercard:

VISA Mastercard

(We can accept only those two.)

Enter your name exactly as it appears on your credit card: 

Is your billing address different from the mailing address you entered in section A of this form above?  If so, please enter your credit card billing address in this box:

Please carefully enter your credit card number in this box: 

Please enter your credit card's three-digit "CCV" number (explanation at right): 

Please enter the month and year when your credit card expires in these boxes:

Month of expiration: 

Year of expiration: 

That's it!  Look back over everything you've entered, and when you're ready, click the "submit" button below.  You'll be taken to a new page summarizing all of your information that you will print and mail in to HMWF.