East End
Counselors Association
A CHAPTER OF THE NEW YORK STATE COUNSELOR ASSOCIATION
2007-2008 Membership Application
o Please check here if there has been no change
in your information.
Name______________________________ Current Position_____________________
Home Phone_______________ Business Phone _______________Fax_____________
Home Street Address____________________________________________________
City________________________________ State______________
Zip_____________
Email_______________________________ Date of application___________________
Name of Institution_______________________________________________________
Business Street Address___________________________________________________
City________________________________ State_______________
Zip____________
Elementary School__ Middle School__ Junior H.S.__
Senior H.S.__ Agency__College__
Send mail to my: Business Address__ Home
Address__
Membership Type: Renewal__ New Member__
Membership Classification (Circle Appropriate One):
Dues: Regular $20 Retired $10 Grad Student $10 Lifetime
Member FREE
Please mail this application form together with
your check payable by Sept. 30, 2007 to:
East End Counselors Association
Anastasia Mouyiaris, Membership Chair
P.O. Box 1357
Riverhead, N.Y. 11901
Purchase orders may be used. Please duplicate
this application and send a completed
membership form for each person wishing to join.
o I hereby grant permission for my image to be used
on the East End Counselors
Association website.
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