Your Name: Street Address: City: State: Zip Code: Home Phone: Your Email: Membership Type: Regular Member $50.00 Sponsor $100.00 Patron/Corporate $250.00 Benefactor $500.00 & up Questions: Method of Payment:    Check | Credit Card | Bill Me Credit Card #: Expiration Date: Please Send Once If your browser is not Javascript enabled, please print this form and mail to Historic Petersburg Foundation P.O. Box 691 Petersburg, VA 23804