Membership in the Long Island Chapter
of the
United States Lighthouse Society

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Please print this form, fill it out, and submit it with your dues to the address at the bottom of the form.

New Membership_____     Renewal_____                                                     (Rev. 8/31/2001)

Name
Street Address
Town, State, Zip Code
Telephone (Optional)
E-mail (Optional)

The membership year is October 1 - September 30. Chapter members must be US Lighthouse Society members.

I would like to join the USLHS and the Long Island Chapter: ____ Individual $35     ____Family $50    _____ Senior $30

Any additional donation: $_________          

Would you be interested in volunteering?       If so, please note any special skills or experience below:

 _____________________________________________________________________________________________

(If you are already a US Lighthouse Society member, Chapter dues are: Individual $15. Family $20. Senior $10.)

Please send a check, made out to "Long Island Chapter, USLHS," to:

Membership Department
Long Island Chapter, USLHS
7 Doe Court
Smithtown, NY 11787