League of Women Voters of Rensselaer County Membership
July 1, 2008 - June 30, 2009
| Name:
|
|
*Household Member Name (if applicable):
|
| Mailing Address:
|
| Phone & Email Address
|
| Location of your Polling Place :
|
| Dues (Please check appropriate category) : |
| $45 ___ Individual Member |
| $70 ___ *Household Membership (second member at same address) |
| $75 ___ #Sustaining Individual Member |
| $100 ___ #Sustaining Household Membership |
| $_______ Additional Contribution |
| $ _________ Total |
|
Optional Comments/Direction to Board:
|
Please make check payable to: LWV of Rensselaer County
Mail your check and this form to: Irene Wynnyczuk, LWV
Treasurer, 11 Diana Lane, Troy, NY 12180
#Sustaining Memberships provide a contribution to the LWV above regular dues.