Membership Application

Individual Membership
(over 18 years old)
$  45.00
Family Membership
(includes children up to 18 years old)
$  65.00
Junior Membership
(under 18 years old)
$  25.00
Sustaining Membership $  55.00
Supporting Membership $  90.00
Sponsoring Membership $  160.00
Life Membership $  425.00

Please repeat the information below for each family member if you are ordering a family membership.
Name: _____________________________________
NETRA Number (renewals only): _____________
Date of birth: ____/____/_____
E-mail: ___________________________________
Phone: ____-____-_____
Address: ___________________________________
City: ______________________________________
State: ____________________ Zip: ___________

Mail this form with payment made payable to NETRA.

NETRA
Post Office Box 1235
Derry, NH 03038