To apply for membership in this active and dedicated association, complete this membership application and mail it, together with your check, money order or credit card info payable to N.S.L.G.A., P.O. Box 489, Brightwaters, NY 11718.  Telephone (631) 665-2250

Firm Name:  ___________________________________________

Your Name:  ____________________________________________

Mailing Address (Street or P.O, Box)  ________________________________

City:______________________       State:_____        Zip Code: _________

Business Phone: (____)_________________
 
Home Phone: (____)_______________   Fax No: (____)_________________

Cell No: (_____)_____________________

E-Mail Address:  _____________________________

Fill in all that apply to your business (if you have a pending number, mark “pending” and call office when you receive the number).

Federal ID No. ________________    NYS Sales Tax No:______________

Consumer Affairs No:_____________     Expiration Date: _ _ /_ _ /_ _ _ _

NYS DEC Registered Business No: _________________________

NYS DEC Pesticide Applicators No: C______________________

Choose One:  Suffolk Chapter ___    Nassau Chapter ___ 

                                    W. Nassau/Queens Chapter ____

Yearly Dues:  $175.00         Check No. _____________

Credit Card:  (  )Am Ex (  )Visa  (  )MC  Card #  _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

 Exp. Date:  _ _ / _ _ / _ _ _ _

Card Billed to:   ________________________________________