American Lighthouse Foundation

MEMBERSHIP FORM

Membership Level:

□	Superintendent (lifetime)	$ 2,500
□	Commissioner	$ 1,000
□	Deputy Commissioner	$ 500
□	Lighthouse Inspector	$ 100
□	Keeper	$ 50
□	Assistant Keeper	$ 25

□	Please send only my membership card
□	Additional Donation	$_________

Please Print:

Name: _____________________________________

Address: ___________________________________

___________________________________________

City, State, ZIP: ____________________________

Phone: ____________________________________

Email: _____________________________________

Payment Info:

Total Enclosed $ ___________

□ Check enclosed or

□ Charge my Visa or MasterCard

# ______________________________ Exp Date: _______

Please note that all memberships are processed by volunteers and it could take up 4-6 weeks for processing. If you need faster service, please advise us and we will do everything to process the order earlier.

Print and mail completed form with payment to:

American Lighthouse Foundation

PO Box 565

Rockland, Maine 04841

Phone 207-594-4174