Name: ________________________________________________________________

Address: ______________________________________________________________

City: ___________________________________ State: _________ Zip: ___________

Phone: (___________)___________________________________________________

E-mail address: ________________________________________________________

Would you like the above information published on the NOS home page?

No_____ All info_____ Name only_____ Name/phone_____ Name/e-mail_____

Would you like to be added to the NOS e-mail list? yes_____ no_____

Would you like to participate in the Rare Bird Alert? yes_____ no_____

Membership dues

___Student $5.00

___Individual $10.00

___Family $12.00

___Sponsoring $15.00

___Sustaining $20.00

Make check payable to: Natchaug Ornithological Society

Mail membership form to: Natchaug Ornithological Society, PO Box 192, Mansfield Center, CT 06250

Please print this form and return it with your check to the address above.