NY StateWide Membership Application Form

Please use our new Membership form to renew or join!

Click HERE

Type of Membership

Choose Membership Type

Today's Date

Date

Individual Membership (Check/Money Order discounted price: $20. Full price for credit card users: $20.90/year)Couple Membership (Check/Money Order discounted price: $25. Full price for credit card users: $26.05/year)Lifetime Membership/Individual (Check/Money Order discounted price: $150. Full price for credit card users: $154.80/year)Lifetime Membership/Couple (Check/Money Order discounted price: $200. Full price for credit card users: $206.30/year)Organization Membership (Check/Money Order discounted price: $75. Full price for credit card users: $77.55/year)

New MemberRenewing Member

Name*

First NameLast Name

Name #2 (for couple membership)

First NameLast Name

Name of Organization (If Applicable)

E-mail

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Chapter (if known)

Phone Number*

Format: 000 000-0000.

PAYMENT METHOD

To pay by check: Mark "check" on the next question. Please make check payable to: NY StateWide Senior Action Council. Then, mail check to: Gail Myers, 46 Commonwealth Dr., Glenmont, NY 12077. Press submit.

To pay by card: Mark "Credit card" on the next question. Fill out this form with your card information, then press submit.

QUESTIONS? Call 518-703-2617. THANK YOU!

CashMoney OrderCheckCredit Card

Total

Credit Card Price

SF Opp Stage*

SF Opp Member Level*

SF Opp Membership Start Date

Date

SF Opp Membership End Date

Date

SF Opp Membership Origin*

Credit Card Payment

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

New York StateWide Senior Action Council Membership Application