The County Leitrim Society of New York

First Name:      Last Name: 

 Address:      Apt: 

 City:      State:      Zip:

 Home Phone:      Work: 

 E-mail: 

 Father’s Name:

 Mother’s Maiden Name:

 Sponsor: 

Membership Fee: $20 per person or $30 per couple

 Meetings are held the third Thursday of each month.  The location will be announced in the monthly newsletters.