Membership Form

Chesapeake Chapter of the U.S. Lighthouse Society – Membership Form

Instructions for submission:

1. FILL OUT FORM. Fill in all required fields in form below.  Or complete only step 2 to print a blank form to give a friend.
2. PRINT. Click the print button on the upper right corner of the page, make 2 copies, one to send with your payment and one for your records.
   NOTE: If you click the submit button without printing first you will lose all the information entered.
3. SUBMIT. Click the continue button, your form will be sent electronically to our Membership Chair. You will be sent to the payment page.
4. PAY. On the payment page you can pay via PayPal or follow the directions for mailing your check made payable to: Chesapeake Chapter P. O. Box 178  Joppa, MD 21085-0178
     WE PREFER YOU ORDER YOUR MEMBERSHIP THROUGH OUR LOFT, AND IF JOINING MANUALLY PLEASE PAY VIA  PAYPAL AS IT SAVES OUR VOLUNTEERS WORK.  THANK YOU!

Name * First Last E-mail * Address * Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Phone: * - Area Code Phone Number This membership is a: * Select valueNew ApplicationRenewalChange to ExistingGift Type of membership: * Select valueIndividual: $15.00Family: $20.00Students: $10.00Seniors (55 +): $10.00* Keeper: $50.00* Inspector: $100.00* Superintendent: $250.00* Lifetime (One Time Fee): $750.00** Keeper’s Mascot (One Time Fee) $2.50 Name of Mascot (if applying for pet mascot membership) Mascot breed (if applying for pet mascot membership) Payment via: * Select valuePayPalCheck/Money Order Do you wish to be included in the Chapter email news group? * Yes No If new application, how did you hear about us? We also welcome your comments: Word Verification: type_submit_reset_13 ContinueReset