First Name:
Last Name:
Address: City:
State: Zip Code:
Phone #'s (in case we need to contact you about your application):
Day: Evening: Fax:
E-mail address:
Payment may be made by Check, Money Order or Visa/MasterCard payable to East End Seaport.
Name on Credit Card:
Visa or MasterCard Card #:
Expiration Date:
Level of Membership (Please see the Membership page for benefits):
Admiral - $1000 and Up Commodore - $500 Captain - $250
First Mate - $100 Dual/Family - $40 Individual - $25
Enclosed is an additional $ to help support the Foundation Activities.
East End Seaport Museum & Marine Foundation Membership Application
(Print out this form and mail to the address at the bottom of the form. Please DO NOT send credit card information by e-mail)
Please mail or fax this form to:
East End Seaport Museum & Marine Foundation PO Box 624 Greenport, NY 11944 Telephone: (631) 477-2100 Fax: (631) 477-3422
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