Wisconsin Regional Lily Society

Membership Application Form

Date of Application:  Month ___________ Day _______ Year __________

Application type:  ____ New     ____ Renewal

Name:    ____________________________________________________

Address: ____________________________________________________

Address: ____________________________________________________

City:    ____________________________________________________

State/Province: _____________________________________________

Country: ____________________________________________________

ZIP/Mailing Code: ___________________________________________

Telephone:        ___________________________________________

Email:            ___________________________________________

Check the desired class of membership:
Class                 Annual Dues        Dues are to be paid by
_____  Individual       $8.00           January 30 of each year.

_____  Household        $8.00

_____  Junior           $3.00

Name tags (optional)  Call Helen Corbett at 715-726-1198 for price

Name for name tag 1: ________________________________________

Name for name tag 2: ________________________________________

Make your payment (check or money order) in US dollars payable to:

Send your completed membership application and payment to:

Wisconsin Regional Lily Society

Helen Corbett

7634 185th Street

Chippewa Falls, WI USA 54729