Membership Application Form

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Kissena Park Civic Association
Application for Membership

Your Name(s): _____________________________________________

Address ____________________________________________________

Zip Code ____________

Telephone number _______________________________________

FAX number ___________________________________________

E-mail address __________________________________________

 Pay $15 for family membership.
Pay $10 for senior citizen membership.
Voluntary contribution

Total enclosed ---------------------------------------- $_____



Please mail this application to:

Kissena Park Civic Association, Inc.
P.O. Box 580423 Flushing NY
11358-0423




* Yearly dues are payable by January 1st of each year. New members who join after September 1st are paid through the following year.