Name_____________________________________

 Address___________________________________

 City_________________ State____ Zip_________

 Is this a new membership? ____Yes  ____No

 Phone (          )______________________________

 E-mail ____________________________________

 Membership year runs from September to August.  Members who first joined after April 2010 are good through September 2011.  For a 2011–2012 Membership, please complete this form(or a photocopy) and return to:

Ms. Marilyn Wiley, HBC Treasurer, 47 Washington Mountain Road, Becket, MA  01223

 Please enclose a check in the Total amount below, made payable to “Hoffmann Bird Club”

 2011–2012 Annual Dues: ($15.00 individual, $20.00 family, $5.00 student, $30 to $50 Sustaining Member)

(Dues support Speaker Programs, Outreach Programs, and donations to organizations with shared goals)

                                                                                     $____________

 Gift (please check below):                                         $____________

 ___ Marilyn Flor Campership Fund  

 HBC Window Decal                                                  $____________

($3.00 each + self-addressed, stamped envelope)        

 1 decal is included with each new membership

 HBC Iron-on Patch                                                   $____________

($5.00 each + self-addressed, stamped envelope)        

 TOTAL ENCLOSED                                              $____________

 ******************************************************************************

 Do you wish to be on the EMAIL hotline?  ______________

 Do you wish to be on the telephone hotline?  _____________ (if you have no email capacity)

 Do you wish to be included on a membership list shared with other members only?  _________

 (Students under 16 must be accompanied by a designated adult on all birding trips.)