New York State African Violet Society, INC.

APPLICATION FOR MEMBERSHIP

Kathy Garbarino
Membership Chairman
5854 Cooper St. Vernon, NY 13476
tel: 315-829-3679
kgarb@twcny.rr.com

Date: _____________________

Please enroll me/us as a member of the New York State African Violet Society, Inc.
_ Dues are enclosed. _ Check if this is a renewal

PLEASE SELECT THE CLASS OF MEMBERSHIP

_ Individual Membership $15.00

_ Joint Membership $5.00 extra for second person
(Two members in the same household)

_ Life Membership $150.00

_ Commercial Membership $20.00 Annually

_ Affiliate Membership $20.00 Annually

Name: ___________________________________________

City: ______________________ State/Prov: _______ ZIP: _______________

Email Address: ___________________________________________________

Signature: ______________________________________________________

Telephone number: _______________________________________________

Make checks or postal money orders payable in US Funds to: NYSAVS
Please list any other African Violet Societies or Clubs of which you are a member.

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