VIP Lifetime Membership
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The "Long Island Shooting Center Gun Club" is an NRA Certified shooting facility and is
recognized by the "New York City Pistol Permit Section" as an "Approved" shooting range.
Please allow 7 business days to receive your membership documentation. If you prefer,
you may fax the information below to (631) 665-7002 or call us at (631) 665-7011.


        First Name: 
       Middle Name:  "None" If no middle name
         Last Name: 
    E-mail Address:  i.e. john@aol.com

     Street / Apt#: 
       City / Town: 
             State: 
               Zip: 

      Phone Number: 
     Date of Birth:  MM/DD/YYYY
        Occupation: 

NYS Pistol Permit#: 
        Issue Date:  MM/DD/YYYY

  Drivers License#: 
   Expiration Date:  MM/DD/YYYY


          VIP Lifetime Membership Dues Include New York State Sales Tax
         Duration:   Lifetime $1520.75

 Credit Card Type:   MasterCard   Visa  Discover

       Card Number: 
   Expiration Date:  MM/YY
    Card Issued To:
Please use the space below for comments, (if necessary):

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