Lazicki's Bird House and Rescue

Membership Form

Please Print

For membership, please send a check or money order along with the form to:

Lazicki's Bird House & Rescue
PO Box 380715
East Hartford, CT 06138

____Individual ($15)

____Family ($25)

____Supporting ($50)

____Angel ($100)

____Lifetime ($1,000)

Date:
Name:
Email Address:
Street:
Street:
City/State/Zip:
Phone Number:
Number in household:
Do you have birds?
If so, what kind?	____________________________ ____________________________ ____________________________

Lazicki's Bird House & Rescue, Inc. is a private 501(c)3 non-profit organization. Your donation is tax deductible in accordance with IRS regulations. Please check with your accountant for details.