(A non-profit Organization)
366 North Broadway, Suite 410-A1, Jericho, New York 11753
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Membership Update
Name: _____________________________________________
First M Last
Spouse’s Name: _____________________________________
Address: ___________________________________________
___________________________________________________
Telephone Number: Home:____________________________
Work/Cell (optional): ____________________________
Email address: ______________________________________
Do you want to be listed as members on the IALI website:
___Yes. ____No.
Please mail the completed form at the following address. You can also fax the form at 718-638-4033 or email the updated information at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
366 North Broadway,