!

!

BLACK LAKE ASSOCIATION

Membership Application!

!

!

Black Lake

Association, Inc.

2996 County Route 6 Hammond, NY 13646 315-375-6631 www.blacklakeny.com/ lakeassoc!

!

Name: _____________________________________________________ Name: _____________________________________________________ Permanent Address: __________________________________________________________

__________________________________________________________ (City) (State) (Zip)

Black Lake Address: __________________________________________________________

__________________________________________________________ (City) (Zip)

! Please check if this is a mailing address. From: ________________ To: _________________ (Date) (Date)

Winter Address: (if different than Permanent)

__________________________________________________________

__________________________________________________________ (City) (State) (Zip)

! New ANNUAL FEE: $20.00 ! Renewal Year: _______________ ! Referred By: _________________________________________

(Current Member Name)

Interests / Comments: ________________________________________ __________________________________________________________

Mail with check or money order to: Sherry Watson, Treasurer Black Lake Association 2996 County Route 6 Hammond, NY 13646