MEMBERSHIP APPLICATION FORM Yes! Please enroll me as a member entitling me to all membership privileges through May 31, 2017.
Name:

Address:	Apt:

Phone:

Email:

Enclosed is:	A check for $10 per membership or $20 for a family membership. Make the check payable to The West 76th Street Block Association, Inc.
	An additional contribution of $

For a family membership, please list all additional family members 18 and older:


Email or mail completed Membership Application, along with your check payable to “The West 76th Street Block Association, Inc.”, to Collette Shine, Treasurer, 153W76#A, email address .