Long Island Center for Independent Living, Inc.  
  Membership Application  
  Membership dues are $5.00 for a one-year term and directly support the Center's equipment purchasing, programs and consumer services. As a non-for-profit organization, LICIL is reliant on both, individual and corporate donations.

Donations can be made in memory of those who have passed away or in recognition of birthdays, holidays or special occasions throughout the year. LICIL also accepts monetary or property contributions by way of charitable bequests and wills. Please consult with your attorney for possible tax benefits.

To become a member please fill out this form and send your tax-deductible membership dues and/or contribution to the Long Island Center for Independent Living, Inc., 3601 Hempstead Turnpike, Suite 208, Levittown, NY 11756.(Please fill out and print this form and send it along with your check to the address above.)

Checks should be payable to LICIL.
(Please note that you will become a member upon receipt of dues.)


 

NAME

ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE

E-MAIL

1 year membership:
$5

Contribution
$25 $50 $100 $200 Other:

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