Fill out the form below or print and mail form to: LIPC, 90 Pennsylvania Avenue
Massapequa, New York 11758


Membership Type
Individual $35     Family $45     Contributor $50    
Student/Low Income $15     Friend $100     Other

I wish to become a monthly sustaining member. My Monthly Pledge is for:
$5     $10*     $20*     $50*     $100*     *Receive a FREE Tote Bag

Please send to me
Short-sleeve Tee Shirt, white $15     Short-sleve Tee Shirt, black $15    
Long-sleeve Tee Shirt, white $18     Long-sleeve Tee Shirt, black $18    
Tote Bag $12                   *Please add $2.50 for postage for all items

Method of Payment:
Pay Online     Mail a Check

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Phone Number:
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Organization (if any):

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**LIPC is a 501(c)(4) non-profit non-partisan organization. Contributions are not tax deductible.