LACKAWANNA
AUDUBON
SOCIETY
NEW MEMBER APPLICATION

Members Name ________________________________________

Address ______________________________________________

              ______________________________________________

Telephone  (_____)______________________________________

MEMBERSHIP CATEGORIES AND CONTRIBUTION OPTIONS
(fill in with appropriate amounts)
    Single  ($10.00 annually)………………………………..  $___________

    Family ($20.00 annually)………………………………    $___________

    Sponsor ($25.00 annually)…………………………….    $___________

    Life ($200.00 - one time payment)…………………….    $___________

    Contribution to Memorial Fund …………………….....    $___________
    (Given in memory of _____________________)
    (Given in honor of _______________________)

    Adopt the Wandering Tattler newsletter ........................    $___________
    ($20.00 per issue to defray mailing cost)

    Additional Contributions to LAS……………………....    $___________

TOTAL PAYMENT ENCLOSED………….…..............    $___________
       (Make checks payable to:  Lackawanna Audubon Society)

Return this form and payment to:                Lackawanna Audubon Society
                                                                 P.O. Box 1372
                                                                 Scranton, PA  18501-1372