Membership Application Oct 2007 – Sept 2008

Name ________________________________________________________________

Address ____________________________________________ Shoreham, NY 11786

Phone __________________ E-mail ____________________________________

(Contacting you by e-mail significantly reduces our costs –

e-mail addresses are not shared )

Please send your check for $20 to

Shoreham Civic Organization, P.O. Box 944, Shoreham, NY 11786

Date Received _________ Amount _________ Ck# ______________