29 Pond Road
Hawley MA 01339
(413) 339-5347
fax:(413) 339-4377
Membership Application | |
| Name: _________________________________________________________________ | |
| Address: ________________________________________________________________ | |
| City: ____________________________________________________________________ | |
| State:_____________________________ | Zip Code: ________________________ | Date of Birth: ________________________ | Telephone: (day) (______) ____________ |
| Date:_____________________________ | (evening) (______) __________________ |
| Chapter:_______________________________________________ | |
| Email:_________________________________________________ | |
| Check MasterCard VISA | |
| Account #_____________________________ | Exp._______________________________ |
| Signature______________________________ | Date______________________________ |
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Annual Membership $60 Individual_____ Annual Membership $100 (couple) _____ Annual Membership $150 (corporate)_____ |
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