Membership Application

Please note: there is a $15.00 application fee. You will be contacted by our Membership Chairperson.  Please print out this form and mail completed form to : Cellini Lodge # 2206, Membership Application, 2208 Jericho Tpke, New Hyde Park, NY 11040

Name:
Address:
Phone Number:
Business Phone Number:
E-mail Address:
Birthday:
Are you a U.S. citizen? yes

no
Are you of Italian ancestry? yes

no
If you are not of Italian descent, is your spouse of Italian descent? yes

no