YES, I WANT TO BE A MEMBER!

SENEME MEMBERSHIP APPLICATION

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

Occupation: __________________________________________________________________________

School/Business Address: ________________________________________________________________
                                                       ^Street
                                                       ________________________________________________________________
                                                      ^{City, State, Zip Code}

Home Address: ________________________________________________________________________
                                  ^{Street                                                                                             
                                 ___________________________________________________________________________________
                                 City, State, Zip Code}

Home Phone: ______________________________   Work Phone:  _____________________________ 

E-mail Address: _____________________________________________________________________ 

Send SENEME mailings to: (Please Check One)

_____ Home Address

______Work Address
 

Membership Category (Please Check One):

_____ Active Member (1 Year $15)

_____ Active Member (2 Year $25) 

_____ Active Member (3 Years $35)

_____ Organizational Memberships (Non-Profits Only $100)

_____ Corporate Membership (1 Year $250)

Total Enclosed: __________

Please return form with checks payable to SENEME.

Mail to SENEME
c/o Julie P. Ainsworth
31 Green Springs Dr.
Madison, CT  06443