Please complete this form and send it along with your payment to the above address.
Please make all checks/money orders payable to Conneaut Lake Institute, Inc.

Name_________________________________________________________________

Address________________________________________________________________

City_________________________________State________Zip____________________

Phone____________________________Cell/Other_____________________________

Email Address_______________________________________________

Address_________________________________________________________________

One Year Membership ($10.00)_________  Five Year Membership ($40.00)__________

Special Interests: (artistic, musical, educational, etc.) _______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Thank You for supporting the Conneaut Lake Area