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To join the Long Island Herpetological Society, Print this page, fill out the following application form and mail with your $25.00 check or money order ( made payable to the L.I.H.S. ) to the following address: Long Island Herpetological Society ============================================================ LONG ISLAND HERPETOLOGICAL SOCIETY MEMBERSHIP APPLICATION NEW MEMBER __________ PREVIOUS MEMBER __________ NAME______________________ DATE __________ ADDRESS
____________________________________________ CITY STATE ZIP ____________________________________________ PHONE ( OPTIONAL, BUT HELPFUL ) : ____________________________________________ OTHER HERP SOCIETIES YOU BELONG TO ( OPTIONAL ) ____________________________________________ TYPES OF HERPS YOU KEEP OR HAVE KEPT \ SPECIALTY AREA ____________________________________________ WHERE DID YOU HEAR ABOUT THE LIHS ? (please circle any that apply) 1. NEWSPAPER CLASSIFIED 2. NEWSPAPER COMMUNITY SECTION (paper name) 3. FRIEND 4. PET SHOP (name) 5. TELEVISION and/or RADIO SHOW (program/station) 6. REPTILE MAGAZINE(name) 7. PUBLIC EXHIBITION 8. OTHER
Name of Person Who Referred You to the Long Island Herpetological Society ____________________________________________ |