Patchogue Civic Association  

PATCHOGUE CIVIC ASSOCIATION

P.O. BOX 1295, Patchogue, NY 11772

2008 Membership Application

PCA membership is open to all residents and business owners located in the Incorporated Village of Patchogue. 

Dues:  (circle one)    $15.00 individual          $20.00 family*          $40.00 business*

Family and business memberships: Please list all family members (residing in the residence) or business owners over the age of 18.

Name(s):  ________________________________,_____________________,_______________,

________________,_________________,_________________,__________________.

No. and Street:  ____________________________

Telephone Number_________________________

Email:  ___________________________________

Please identify civic or social issues that are most important to you.

 (circle:    1=most important;     5 =least important):

1 2 3 4 5 Parks and Recreation

1 2 3 4 5 School Issues

1 2 3 4 5 Zoning Issues

1 2 3 4 5 Traffic / Speeding/Roads

1 2 3 4 5 Crime and Public Safety

1 2 3 4 5 Economic Development

1 2 3 4 5 Neighborhood Events and Activities

1 2 3 4 5 Neighborhood Beautification

1 2 3 4 5 Other ___________________________________________________________

*Each family or business is limited to two votes on regular Association business or elections.  All listed family members or owners of a particular business may attend all Association meetings and regular membership function

For More Information

info@patchoguecivicassociation.com

Print this page and mail completed application with check to Patchogue Civic Association PO Box 1295 Patchogue NY 11772