Membership Application

 

Name: ________________________________________________________

 

Address: ______________________________________________________

 

City: ________________________ State: __________ Zip Code: ________

 

Home Phone: _(        )_____________ Work Phone: _(         )____________

 

E-Mail: _______________________________________________________

 

Club Affiliation: ________________________________________________

 

Type of Vehicle you own: ______________________________________

 

Check one:  New Member:    Renewal:    LSSRA No: ( _____________ )

 

Membership fee is $25.00 per year. Membership includes: Membership Card,
LSSRA Streetlight Newsletter for a year and a windshield decal.

 

 

 

COMPLETE FORM AND MAIL TO:

 

LSSRA

PO BOX 97

DEPORT, TEXAS 75435