WEST SIDE FEDERATION OF NEIGHBORHOOD

MEMBERSHIP APPLICATION/DUES NOTICE FOR 2011

Organization’s Name: ___________________________________________________

                    Address:  ___________________________________________________

                     E-Mail:  ___________________________________________________

Type of Application:  _____  Block Association ($25)
                                    _____  Neighborhood Association ($25)
                                    _____  Co-op/Condo ($25)
                                    _____  Tenant’s Organization ($25)
                                    _____  Individual ($25)
                                    ______Other (Please specify below) ($25)

Are you incorporated (Y/N) _______                         Year of incorporation:  ______
Do you have by-laws (Y/N) _______                         Number of Members:    ______

If Other:          Name:     ___________________________________________
                       Address: ___________________________________________

Names of Officers:

            1.         Name and Title: ________________________________________
                        Address: ______________________________________________
                        Contact Telephone: __________________    Fax:______________

           2.         Name and Title: ________________________________________
                       Address: ______________________________________________
                       Contact Telephone: __________________    Fax:______________

           3.         Name and Title: ________________________________________
                       Address: ______________________________________________
                       Contact Telephone: __________________    Fax:______________

You may choose any one of the above officers as a delegate to our meeting for voting purposes, or you may assign another delegate. 
Please fill out the section below to assign your delegate.

Delegate’s Name: ________________________________   Date: _____________

Signature of President: ____________________________

P.O. Box 447, Ansonia Station, New York, NY 10023

(212) 969-8047

e-mail:  westsidefed@aol.com