Membership Form



Membership Application For


Last Name:   _____________________     First Name: ______________________           Date: ______________
                                                                                         

Address: ____________________________________________________ Phone: ________________________


Membership Level: ______________________________ E-Mail address: _______________________________


Signature: _______________________________________________

Yearly Membership levels:

Seniors (55 plus) $25.00    Individual $30.00    Family $35.00    Lamplighter $100.00    Keeper $250.00   Grand Keeper $1000.00


Mail membership application and fee to: 

Ashtabula Lighthouse Society 
P.O. Box 221
N. Kingsville, Ohio 44068
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