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 $20.00 per year. Membership includes: Membership Card,
LSSRA Streetlight Newsletter for a year and a windshield decal.