New York State of Mind Caravan Sign up

Name_____________________________________Name______________________________

Address:_____________________________________________________________________

City_______________________________State/Province__________________Zip__________

Phone______________________E-mail_______________________WBCCI#______________

Pets:___________________Names________________________________________________

Model and length of your Airstream________________________________________________

Deposit is $200.00   $1000.00 Due December 15, 2017, Final payment due April 1, 2018

Send deposit to: Debbie and Mark Hammer, 1647 Park Ave., New Hyde Park, NY 11040

Phone: 516-330-3644 E-mail: debbie@halimer.com