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