CLIA Membership Form

Cossayuna Lake Improvement Association

Annual Membership Form
In order to be a member of the CLIA, you must own property within 1 mile of the perimeter roads of Cossayuna Lake.
Name*

First NameLast Name
Are you a new member of the CLIA?*

NoYes
Address of Lake Property*
Primary Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Seasonal Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Alternate Contact Number
Has your email address changed in the last year?*

YesNo
Email Address*
Personal email address preferred.
Second Email Address (optional)
Personal email address preferred.
Would you like your name and contact information to appear in an upcoming Contact directory?*

YesNo, not at this time
Has your mailing address or phone # changed in the last year?*

YesNo
Please indicate how you would like to receive the Association Newsletter. Help your Association save money by selecting the Electronic option!*

Electronic - sent to me via emailPaper - mailed to me
Membership Option*
prevnext( X )
HOUSEHOLD - 1 vote: 1 OR 2 names. $100
Example: Mary Smith OR Mary & John Smith

INDIVIDUAL - 2 votes: 2 names. $120
Example: Mary Smith AND John Smith

Total $0.00
Name(s) to appear on Membership:*
Do you have specific interests or skill sets that you would be willing to share with the CLIA?
Select a payment method at the bottom of the form. If paying by credit or debit card, fill out your card information and click on the "Join Now!" button.
Questions can be directed to the following individuals:

Membership: Bob Reilly 631.897.4811 or dakotabr1960@gmail.com

Harvesting: Tom LeCours, Harvesting Chair 518.366.1151 or tunamantom@yahoo.com / Gene Henry, Head Harvester 518.744.4768 or newpilotg@roadrunner.com

Lake Management: Sheila Rappazzo 518.429.8312 or sarappazzo@yahoo.com
CLIA is a 501(c)3 nonprofit organization. Donations are tax exempt to the extent of the law. A copy of our most recently filed financial report is available from the Charities Registry on the New York State Attorney General's website (www.charitiesnyc.com) or, upon request, by contacting the New York State Attorney General, Charities Bureau, 28 Liberty Street, New York, NY 10005 or us at POB 81, Cossayuna, NY 12823-0081. You may also contact the New York State Office of the Attorney General at 212.416.8401.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Cossayuna Lake Improvement Association