First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
*Home Phone
*E-mail

  *Optional

Choose One of the Following Membership Levels:

Sustaining Member  -  $1000.00

Patron  -  $500.00

Benefactor  - $250.00

Business  -  $100.00

Friend  -  $50.00

Member  -  $25.00

Student  -  $10.00

To become a member of SCOW, please

Print, Complete and Return this form, along

with your membership dues to:

 

The State Council On Waterways

P. O. Box 43

      Little Falls, New York 13365

 

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