Membership Application

Please use a pen to print the following information:

Name:______________________________________________________________________________

Street Address:____________________________________________________________________

PO Box:_____________________________________________________________________________

City:________________________________________________________________________________

State/Zip Code:_____________________________________________________________________

Organization Represented:_________________________________________________________

Your Position:______________________________________________________________________

Email Address:_____________________________________________________________________

Telephone:_________________________________________________________________________

Annual Membership Categories

 ¨      Individual Membership - $25.00

¨      Supporting Membership - $25.00

¨      Contributing Member - $50.00 or More $___________________

¨      Corporate Membership - $50.00

¨      Supporting Corporate Membership - $50.00

¨      Contributing Corporate Membership - $ 100.00 or More $________________________

 Please make your check payable to LE/AD and mail along with this application to the above address. Total Amount Enclosed:__________________________________

Lakes Education/Action Drive is a non-profit, tax deductible corporation.