Membership Application Form

P.O. Box 240
Coventry, RI 02816

Email: lakemishnockpreservation@gmail.com
Membership Application

To apply for membership please complete all fields. If you wish to donate without becoming a member you can skip the information fields and scroll down the the section labeled "I am donating to the lake fund but do not wish to become a member."
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home Number
Cellular Number
Would you like to serve on a Committee?

YesNo
Do you have any special skills helpful to LMPA?

YesNo
If so, please explain:
I am at least 18 years of age and support the following mission statement:

Lake Mishnock Preservation Association, a nonprofit, all-volunteer organization, is dedicated to the safety, improvement, and protection of Lake Mishnock and strives to ensure its biological integrity and natural beauty for generations to come.
I hereby apply for membership:

Individual $30Household $40
AND, I wish to make an additional donation of

$25.00$50.00$75.00$100.00
...other amount
in USD
I have donated $100 or more and wish to apply for membership.

Please Accept My Donation For Membership.
I am donating to the lake fund but do not wish to become a member

$25.00$50.00$75.00$100.00
...other amount
in USD
Signature

Clear
Date

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Date
Membership/Donation Totals

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