Check all that apply:                                                                                                   Please print.  Thanks☺

New Membership

$45

Membership Renewal $45

LPOYC Burgee

$18

Name:

Phone Number:

(           )            --    

Spouse, Significant Other, Co-Owner, other:

E-mail Address:

                                               @

Mailing Address:

                 Street                                                   City                                                 State          ZIP + 4                      

Boat – Make & Model:

Boat Name:

Sail Number:

Marina where boat is berthed::

Slip Number:

Interests:  (Check all that apply)

Racing

Cruising

Social Activities

Other: