Name:
Address:
City
State
Zip:
Phone:	--
Email:
Please Choose Membership Level:	Individual $25.00 Double $40.00 Family $50.00
Enclosed is my check or money order:
Please Charge my:	Visa MasterCard
Name on Card:
Card #:
CCV Code:	(3 digit code in signature box of card)
Expiration Date:	/    (mo/yr)

Please complete, print and mail form

with your check, money order or credit card information payable to:

Delaware River and Bay Lighthouse Foundation, Inc.

P.O. Box 708

Lewes, DE 19958