Membership Form

Please print, fill out, and mail this form to:

Piedras Blancas Light Station Association Membership P.O. Box 127 San Simeon, CA 93452	Questions? Callour membership staff at 805-927-3719 or e-mail us at: Membership@piedrasblancas.org

or Fax your form to: 805-924-1107

Become a member, renew your membership in the Piedras Blancas Light Station Association, or give a gift membership to a friend!

I am renewing my membership in the Piedras Blancas Light Station Association

I am joining the Piedras Blancas Light Station Association for the first time.

I would like to give the gift of membership to a friend Please choose one of the following membership types and levels below. If you are a renewing member of the Piedras Blancas Light Station Association, please consider renewing at a higher level this year—The Light Station needs your help!

General Membership Friend $ 35 Contributor $50 Sponsor $100 Patron $250 Benefactor $500 Other ____ ($35 minimum)	The Piedras Blancas Society (our premier donor circle for the light station supporters) Assistant Lighthouse Keeper $1000 Lighthouse Keeper $2000 Lighthouse Commissioner $5000

All international members must join at the $50 contributor level or higher.

Piedras Blancas Guardians (a special program of membership for monthly donors—please see our website for more information or call us at 805-927-3719)

The Piedras Blancas Society (our premier donor circle for the light station supporters)

$10/Monthly $15/Monthly $20/Monthy $25/Monthy Other $__ /Monthly

Assistant Lighthouse Keeper $1,000 Lighthouse Keeper $2,000 Lighthouse Commissioner $ 5,000 Other __________

Please charge my credit card on the

1st day

15th day

Last day of the month

After the first payment is received, automatic deductions will occur on the same schedule as stipulated above until you notify the Association that you wish to end this agreement and the Piedras Blancas Light Station Association has had a reasonable amount of time to fulfill your request.

Please give us the following information as you would like it to appear on our membership records: Your Information (if you are giving a gift membership, please give us your contact information below, not the gift recipient’s)

Title: (Mr. Mrs. Miss. Ms. Dr.) ______________________________________

First Name:_____________________________________________________

Last Name: _____________________________________________________

Suffix:_______________________________________________________

Address: _____________________________________________________

Address Line Two: _________________________________________________

Street: _______________________________________________________

City: _______________________________________________________

Zip: ________________________________________________________

Country: (If outside U.S.) _________________________________________

Phone: ___________________________________

Fax: ______________________________________

Email: (see Privacy Policy: _________________________________________

Gift Recipient’s Information (please give us the following information for the person(s) you are giving the membership to, if applicable)

Title: (Mr. Mrs. Miss. Ms. Dr.) _________________________________________________

Fisrt Name : ____________________________________________

Last Name : ______________________________________________

Suffix : ______________________________________

Address Line 1: _________________________________________________________________

Address Line 2 : ________________________________________________________________

City: _________________________________________________________________

State/ Province: __________________________________________________________

Zip/Postal Code : ________________________________________________________

Country (If outside U.S.): __________________________________________________

Phone: ____________________________________

Fax: _____________________________________

Email: _________________________________________________

Please see our Privacy Policy found below

Check here if you’d like to receive Piedras Blancas Light Station Association information and updates such as special events and member benefits, or special discounts on items from the store.

Privacy Policy:

We do not share any of your personal information, including your email address with others without your permission; see our Privacy Policy on our website.

All Piedras Blancas Light Station Association memberships are family memberships, entitling all members of the family living in the same household to the benefits of membership. Please list the first and last names of any family members (who meet the requirements above) you would like included on your Association membership and indicate their relationship to you:

Family Member 1: _________________________________________________________________

Family Member 2: _________________________________________________________________

Family Member 3: _________________________________________________________________

Family Member 4: _________________________________________________________________

Family Member 5: _________________________________________________________________

Please Charge to:

Credit Card:	Visa	MasterCard

Cardholder Name: ____________________________________________________

Card Number: _________________________________________________________

Card Verification Number: _______________________________________________

(located on the right side of the signature line on the back of your credit card)

Card Expiration Date: _____________________________________________

Signature of cardholder: _____________________________________________________________

Or Make Check payable to: Piedras Blancas Light Station Association

Other comments or information:

When you join the Piedras Blancas Light Station Association, you can be satisfied knowing you are helping to restore and preserve a valuable piece of history and irreplaceable relics, to save a spectacular piece of nature, and to protect a national treasure for generations to come. With the help of people like you, we can send a strong message of support for a vital piece of America’s history, and artifacts that were vital to navigation, commerce and trade. Add your voice to those of us who believe that restoration and preservation of this site is vital. Join us in ensuring that the Piedras Blancas Light Station is restored and preserved for future generations and remains a refuge for our children, our grandchildren, and countless others who seek solace and renewal in its remote location rich in history, culture and majestic ocean and mountain views amidst flora and fauna. Your membership counts!

Note: Your membership gift is tax-deductible to the full extent allowable by law.

Thank you for your support of the Piedras Blancas Light Station through an Association membership.