| Name |
|
| Phone |
|
| Organization |
|
| Position |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| E-mail |
(required) |
| How many seniors do you or your organization serve? |
|
| Would you be willing to serve on the NYSCA Board? |
yes
no |
| or on a committee? |
yes
no |
| Dues- Organizations
|
|
| Government Agencies $100 |
|
| Not for Profit Organizations
(budget less than
$500,000) $100 |
|
| Not for Profit Organizations
(budget greater than $500,000) $150 |
|
| For Profit
Bronze Business Supporter $200 |
|
| For Profit
Silver Business Supporter $500 |
|
| For Profit
Gold Business Supporter $1,000 |
|
| Designated voting representative |
|
| Alternate voting representative |
|
| Dues- Individuals |
|
| Individual $75 |
|
| Senior (age 60+) $20 |
|
| Student (enrolled full time at
) $20 |
|
Please
check box for payment:
|
1. check is in the mail
2. please bill us |
|
|
|
