Friends of Historic New Utrecht
New Utrecht Liberty Pole Association
Membership Application
The Friends of Historic New Utrecht and the New Utrecht Liberty Pole Association
encourage you to join us in preserving our proud heritage. Help support our future events and exhibits. If you would like to become a member, please call (718) 256-7173, or print and mail this form with your check to:
Friends of Historic New Utrecht/New Utrecht Liberty Pole Association
1831 84th Street
Brooklyn, NY 11214-2914
□ $10 Annual Membership Fee (□ $15 Couples, □ $75 Lifetime, □ $100 Couples Lifetime) to Friends of Historic New Utrecht and/or
□ $5 Annual Membership Fee (□ $2 Seniors/Students, □ $10 Couples, □ $75 Lifetime) to the New Utrecht Liberty Pole Association.
| Name | ________________________________ |
| Address | ________________________________ |
| City, State | ________________________________ |
| Zip Code | _________________ - _____________ |
| Telephone # | (Day) _______________________ |
| (Evening) _______________________ | |
| (Fax) _______________________ | |
| Signature | ________________________________________ |
| Date | ____/____/________ |
| I wish to be notified of Friends meetings by: | |
| U.S. Mail | (Y) (N) |
| (Y) (N) |
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| Provide address: | ___________________@____________________ |