Please print, complete, and mail with payment or use the links

below to pay online using a secure server.

NAME ________________________________________________________________________

AFFILIATION __________________________________________________________________

ADDRESS_____________________________________________________________________

CITY, STATE, ZIP _______________________________________________________________

PHONE: ______________________________________________________________________

FAX:_________________________________________________________________________

E-MAIL: _________________________________________________________________________

Membership Category	Circle or Click Your Payment
One-Year Individual Forum Membership $35 [Benefits of Membership]	Member Name and Phone Member Address and Email
One-Year Student Membership $15	Member Name and Phone Member Address and Email
One-Year Corporate Membership $100	Member Names and Phones Member Addresses and Emails
TOTAL ENCLOSED	$______

Please make checks out to the New York State Wetlands Forum, Inc.  EIN# 14-1723859. Mail checks and this form to New York State Wetlands Forum, Inc., P.O. Box 1351, Latham, NY  12110-1351, or fax to 518-783-1258.