Individual Membership Application
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For Club Membership
*
Indicates Required Info
*
Type of Membership - Choose One
*
NAME
$25 - Individual - New
$25 - Individual - Renewal
$15 - Junior - New
$15 - Junior - Renewal
$50 - SPONSOR - NEW $50 - SPONSOR - RENEWAL
*
ADDRESS 1
ADDRESS 2
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CITY STATE
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LA
ME
MD
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MT
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OK
OR
PA
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ZIP
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EMAIL ADDR
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DAY PHONE#
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EVE PHONE#
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DONATION
$
Instructions:
Complete this form
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Mail the completed form and a check for the required amount to:
Questions?
C
all: (631) 475-8125
Web Site: www.NYSAFE.Org
S
.
A
.
F
.
E
.
Inc.
PO Box 343
Commack, NY 11725
