_______________________________________________________________________
Instructions:

Please print this page, fill out the information fields, and send
it to the following address with your annual membership dues. 

                HISTORICAL SOCIETY OF ISLIP HAMLET
                       POST OFFICE BOX 601
                         ISLIP, NY 11751

Please make checks payable to: Historical Society of Islip Hamlet.
Thank you.
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                      [ MEMBERSHIP APPLICATION ]


Name of Member(s):_____________________________________________________

Street address:________________________________________________________

Town/State/Zip:________________________________________________________

Phone: Home:________________________ Business:_________________________

Email:_________________________________________________________________

Membership Level:

  [] Family ($20.00 For two adults and $8.00 each additional adult over 18)
  [] Business/Organization $30.00 
  [] Individual(s) ($12.00 per person)
  [] Senior citizen(s) "age 65 and up" ($5.00 Per person)


(1) Would you like to volunteer to assist the Society?
                    
                    Yes[] / Prefer not to at this time[]


(2) Would you like to work on a committee?

                    Yes[] / Prefer not to at this time[]


Comments: ___________________________________________________

          ___________________________________________________

  Your membership will be listed in the next issue of "The Quahog", and on
the website.  As a memeber, you will receive the quarterly mailing of "The
Quahog", as well as other news of the Society’s activities.

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      THANK YOU FOR SUPPORTING THE HISTORICAL SOCIETY OF ISLIP HAMLET!
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