UAYCEF
Membership Application
Name:__________________________ New Member: ___
Renewal:___
Address:_____________________________________________________
City: ____________________________ State:_______ Zip:
_________
Country: ___________________________
Phone: (Home) __________________
(Work)_____________________
Email:
_____________________________________________________
Mobile Phone/Pager:_________________ Fax:
___________________
Please return this application, all checks payable
to: UAYCEF, C/O Chris Nicola, 2446 43 Street, Astoria, NY 11103.
[NOTE: Regular Member dues are $5 per year for individuals, $25 for institutions and organizations, and $100 for lifetime individual memberships]Enclosed $ amount: __________ Cash ___ Check ___ (Please retain a copy of this form for your records)
ver. 6/15/04
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