GLLKA MEMBERSHIP FORM
Please print the form
below. After
filling out the form, you can mail or fax it to the GLLKA office at the address
or
phone number at the bottom of the page. Please be sure to include the type of membership
desired and select one of
the method of payment options below.
Name: _________________________________________________________________________________
Street Address ___________________________________________________________________________
City: ___________________________________________________________________________________
State: __________________________ Zip: _________________ Telephone: _________________________
Email: __________________________________________________________________________________
Please check one of the following, depending on the status of your membership:
[ ] New [ ] Renewal
Please check the appropriate type of membership desired:
[ ] Individual: [
] 1 year ($35) [
] 2 years ($65)
[ ] Family: [ ] 1
year ($50) [ ] 2
years ($90)
CONTRIBUTING MEMBERSHIPS (Includes
First Class Mailing of quarterly Beacon)
[ ] Keeper: [ ] 1
year ($125) [ ] 2
years ($235)
[ ] Inspector: [ ] 1
year ($250) [ ] 2
years ($475)
[ ] Superintendent: [
] 1 year ($500) [
] 2 years ($950)
[ ] Corporate: [ ] 1
year ($2000)
[ ] Life: [ ]
($1500)
Method of Payment:
[ ] Check enclosed [
] Money Order enclosed
If you select check or money order, simply print the completed form and send
it via postal mail. Please make checks
payable to Great Lakes Lighthouse
Keepers Association or GLLKA and mail to the address at the bottom of this
page.
Credit Card:
Please select one: [ ] VISA [
] MasterCard [
] Discover
Credit Card Number:
Expiration date (required):
Please sign here:
Total amount submitted/enclosed:
$
Please make checks payable in
FAX No. (231) 436-5466