Please print and complete this  form and return it along with  a check or money order payable to the  Harry Van Arsdale Jr. Memorial Association, at Local Union No. 3, IBEW 158-11 Harry Van Arsdale Jr. Avenue, 6th Floor , Attention Helen, Flushing, NY 11365-3017 . Membership donation is $35.00.  Any additional donation should be made with a separate check or money order. We look forward to hearing from you and thank you in advance for your support of this exciting project.

Membership Form

Last Name:                   

First Name:                   

Address:                       

City/Town:                   

State:                           

Zip Code:                     

Social Security #:           

  Membership Donation    @    $35.00

   Additional Donation of           $__________________

       Total Enclosed:                      $__________________

 All donations are tax-deductible. IRS Identification No. 11-2803482.