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Membership Application
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Name____________________________________________
Address__________________________________________
City__________________________State_____ Zip_______
Tel: ( ) _____-_______ Fax: ( ) _____-_______
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(please check one)
______Basic Membership FREE. Voluntary Contribution $________
______Supporting Membership $ 99.00 Annually
______Sponsoring Membership $ 199.00 Annually
(please circle one)
Card Number__________________________
Expiration_________Security Code______
Rather pay by check? Please make your heck payable to
NYCOSS,Inc. and mail to the address at the bottom of
the page
Are you a : ____ Daily Smoker ____ Social Smoker ____ Occasional Smoker ____ Former Smoker
Do you Prefer: _______Cigarettes _______Cigars _______ Both Neither________
Are you interested in volunteering for the Coalition?
Are you a business owner affected by the smoking ban?
Would you like to advertise your products/services to members of the coalition?
How did you here about our website?
Comments?______________________________________________________________________________________
Please fax to (631) 382-8214 or mail this form to: New York Coalition of Social Smokers, Inc.
PO Box 704 Commack, NY 11725
