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Membership Application Name: Address: City: State,Zip Telephone: E-Mail Address: Do you wish to be included in the Chapter's email news group?Yes No Membership Type: Choose Family $20.00 Annually *Keeper $50.00 Annually Individual $15.00 Annually *Inspector $100.00 Annually Student $10.00 Annually *Superintendent $250.00 Annually Senior $10.00 Annually *These categories will each receive their newsletter via 1st class mail. Inspectors and Superintendents will receive an appropriate gift. Membership Status: New Application Renewal Change Of Existing If New, How did you hear about us? If another site... which one? Final Comments: Before you continue... PRINT THIS FORM after you have filled in the information. You can also print this form blank and give it to a friend who may not have internet access. The information you submit will never be used for anything other than chapter information. We will never give out your information to outside parties.

Please enclose your check payable to "Chesapeake Chapter, USLHS" and mail it to: Membership Chairman Chesapeake Chapter, USLHS P.O. Box 1270 Annandale, VA 22003-1270, E-Mail: membership@cheslights.org You will receive your first newsletter within two weeks after we have processed your membership form.