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Name: ________________________________________________________________
(Last) (First) (Middle Initial)
Address: _______________________________________________________________
(Street)
_______________________________________________________________
(City) (State) (Zip Code)
Home Telephone: ( )__________________
Work Telephone: ( )__________________
E-mail Address: __________________________________________
Membership Fee: $50 per year Individual_______ Family_______
Send check to:
Chinese Center on Long Island, Inc.
395 Hempstead Turnpike
West Hempstead, N.Y. 11552
ATTN: Membership
Please answer the following questions so we can better serve our members. All responses are kept confidential. Thank you for your cooperation.
1. Number of adults in the household _______________________.
2. Number of children in the household _________,
ages __________________.
3. Your hobbies _______________ _______________
_______________
4. Your spouse’s hobbies _______________ _______________
5. Internet access Yes _____ No_____
6. How did you learn about us?
Center’s website __________
Referred by ______________
Newsletter _______________
Other ___________________
News Media (type) _________________
CCLI Events ______________________
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