Please print, complete, and return this document to:
Fairfax Partnership for Youth, 12011 Government Center Parkway, #1050, Fairfax VA, 22035

Annual Dues

• Youth (up to age 25) - $10.00 per year
• Adult (age 26 and older) - $25.00 per year

Date _________

Name ______________________________________________________________________
Address ____________________________________________________________________
Address ____________________________________________________________________
Home Phone # _______________________________________________________________
Business Telephone # __________________________________________________________
Fax # ______________________________________________________________________
E-Mail Address _______________________________________________________________

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Partnership Giving

(Individuals, Businesses, or Organizations)

• Platinum Level - Above $ 5,000 annually
• Gold Level - $1,000 to $4,999 annually
• Silver Level - $100 to $999 annually
• Bronze Level - Up to $99 annually

Name ______________________________________________________________________
Business/Organization __________________________________________________________
Address ____________________________________________________________________
Address ____________________________________________________________________
Telephone # _________________________________________________________________
Fax # ______________________________________________________________________
E-Mail Address _______________________________________________________________

Please make checks payable to: Fairfax Partnership for Youth, Inc.

The Fairfax Partnership for Youth, Inc. is a private, non-profit, 501(C)(3) corporation. Contributions to the Fairfax Partnership for Youth are tax deductible. Please consult your tax advisor.