THE LEAGUE OF WOMEN VOTERS ^®
OF BROOKHAVEN

Print this page, complete it, and enclose in envelope with a check.  Mail to LWV of Brookhaven, P.O. Box 92, Bellport, NY 11713

First Name ________________________

Last Name _______________________________

Street Address _________________________________________

City ____________________________

State _________________

Zip ____________________

Home Phone ______-______-______________

E-mail ___________________________________

Circle one of the following options.
Make the check payable to "LWV of Brookhaven"

Individual Membership $45

Household Membership $65

Student Membership $21

Additional Contribution $________

Contribution to NYS-LWV Education Foundation (tax deductible) $_________ 
 

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