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Statement of Dues  (Print Out)

New York City     Total Dues  $78.00 Via Paypal

Name:_______________________________________________

Address:_____________________________________________

City/State/Zip_________________________________________

_____________________________________________________

Company Information:____________________________________

Email:

Make check to: Honorable Order of the Blue Goose, INTL

Please print out and send your check to:

Michael Nardulli

900 South Country Road

Bellport, NY 11713