League of Women Voters of Rensselaer County


Membership Form:  July 1, 2011 -  June 30, 2012

Please copy and mail, along with your check, to:

Irene Wynnyczuk, LWV Treasurer
404 McChesney Ave. Ext., Apt. 26-6, Troy, NY 12180 

 

NAME: __________________________________________________________________________________________________________________

 


*HOUSEHOLD MEMBER NAME (if applicable): __________________________________________________________________________________

 

 

MAILING ADDRESS:

Street   __________________________________________________________________________________________________________________

City/Town _____________________________________________________________________Zip Code___________________________________

 

 

PHONE: (Home) ______________________________  (Cell) _______________________________

 


E-MAIL ADDRESS: _______________________________________________________________

 

 

DUES (Please check appropriate category) :

 


Individual Member                                                                         ____    $ 50.00   

 

 

Household Membership (*second member at same address)           ____   $ 75.00  

 


Additional Contribution:  
                                                                                                                      $_________

 


TOTAL:                                                                                                       $ _________

 

COMMENTS (optional):