2022 Membership Dues Voting Member Name * First Name Last Name * Last Name Title (Optional) Title Voting Member Dues Based on Number of Interments Yearly (Check One) * 0-24 – $15.00 25-49 – $45.00 50-299 – $105.00 300-499 – $174.00 500-799 – $368.00 800-1,399 – $683.00 1,400-1,999 – $840.00 2,000 – Over -$998.00 Crematory Member – $158 plus interment fee dues Supplier Member – $263.00 Associate Member – $42.00 Cemetery Name / Organization * Street Address * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Email * Phone Number * Fax Please select one membership category * Cemetery Memorialization Maintenance Construction/Design Accounting Investment Legal Technology Insurance Financial Management Consulting Marketing Other Please select one membership category 2022 Membership Dues Schedule Supplier Members Supplier Members: Please list product or service marketed Cemetery Members Year of cemetery inception Cemetery acreage Exact number of interments last year Associate Members at $42.00 each. (Same benefits as voting member.) Please select the number of Associate Members One +$42.00 Two +$84.00 Three +$126.00 Four +$168.00 Five +$210.00 Six +$252.00 Seven +$294.00 Eight +$336.00 List the Names of the Associate Members List the Names of Email Addresses for Associate Members Payment Information Additional contribution to support your Association Pay by I will be paying by Credit Card/Paypal Online I will be paying by check Total Due $ *2022 dues payments are due by January 20, 2022. * If you have any questions please call the NYSAC office at (518) 434-1134. This information will be listed in our membership directory and on our website. Please make checks payable ONLY to: New York State Association of Cemeteries. Please do not use acronyms such as NYSAC. *The information submitted will be available to membership online and in the NYSAC publications, unless requested otherwise. Mail form and payment to: New York State Association of Cemeteries 111 Washington Avenue, Suite 501 Albany, NY 12210 Phone (518) 434-1134 Fax (518) 427-0452 firstname.lastname@example.org www.nysac.com If you are human, leave this field blank.