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!
!
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