Please provide us with the following information, then SUBMIT the form at bottom   Name: E-Mail: Company: Title: Company Address:   City:  ,  State:   Zip: Business Phone:   Fax: Home Address:   City:  ,  State:   Zip: Home Phone:   Fax:    I prefer to receive mail at the Office or at Home How did you hear about the LI Center? If referred, referred by? Please provide a brief statement describing your business or profession, or place your resume (ascii format) here . Annual Membership Fee: $125  for Individual $300  for Business $600 for Corporate (up to 10 members) To pay via credit card, call us at 631.673.0209  Please send a check, made payable to LI Center in the above amount to: 165 PIDGEON HILL ROAD HUNTINGTON STATION, NY 11746 For help with this application or other information, please call 631.673.0209 or fax 631.673.0905.