LACKAWANNA                 
AUDUBON
SOCIETY        MEMBER APPLICATION

Members Name ________________________________________

Address ______________________________________________

              ______________________________________________

Telephone  (_____)______________________________________

Email address __________________________________________

MEMBERSHIP CATEGORIES AND CONTRIBUTION OPTIONS
(fill in with appropriate amounts)
    Single  ($10.00 annually)������������..  $___________

    Family ($20.00 annually)������������    $___________

    Sponsor ($25.00 annually)�����������.    $___________

    Life ($200.00 - one time payment)��������.    $___________

    Contribution to Memorial Fund ��������.....    $___________
    (Given in memory of _____________________)
    (Given in honor of _______________________)

  Additional Contributions to LAS��������....  $___________

TOTAL PAYMENT ENCLOSED����.�.............. � �  $___________
       (Make checks payable to:  Lackawanna Audubon Society)

Return this form and payment to:           Lackawanna Audubon Society
                                                                 P.O. Box 1372
                                                                 Scranton, PA  18501-1372