AQUEHONGIAN LODGE 112		STATEN ISLAND COUNCIL BOY SCOUTS OF AMERICA PO BOX 131472 STATEN ISLAND NEW YORK 10313
MEMBERSHIP RENEWAL (OCTOBER 1, 2010 – SEPTEMBER 30, 2011)	MAKE CHECKS PAYABLE TO: GREATER NEW YORK COUNCILS BSA (In the memo section, indicate “Aquehongian Lodge 112 Dues”)

CHECK ONE

— 1 YR. 2010-2011 ($12.00) — 2 YRS 2010-2012 ($24.00)

— LAPSED DUES PAYMENT ($24.00) – WILL BE CURRENT UNTIL 9/30/11

— PLEASE REMOVE MY NAME FROM THE ACTIVE MEMBERSHIP LIST

PLEASE PRINT NEATLY SO WE CAN VERIFY RECORDS

NAME:

ADDRESS:

CITY: STATE: ZIP

EMAIL ADDRESS: ——————————————————————————

TELEPHONE NUMBER(S) HOME: CELL:

I AM WITH TROOP or CREW

— I AM OVER 21 — I AM UNDER 21 AND MY BIRTHDATE IS:_____/_____/________

MEMBERSHIP: ORDEAL YEAR BROTHERHOOD YEAR VIGIL YEAR

WHAT COMMITTEES WOULD YOU LIKE TO SERVE ON THIS YEAR

—ACTIVITIES	—BROTHERHOOD	—CAMP PROMOTIONS	—ICE
—DANCE TEAM	—ELANGOMAT	—SERVICE	—MEMBERSHIP
—ORDEAL	—PUBLICATIONS	—UNIT ELECTIONS	—WEBSITE
—CEREMONIAL RING	—NIAMAT	—CONCLAVE	—FUND RAISING
—COMMISARY	—TROOP REPRESENTIVE	—SHOWS

PLEASE SEND THIS COMPLETED FORM AND PAYMENT TO:

EMILY CUEVAS

72 EDWARD STREET

ISELIN, NJ 08830