Louisiana Delta 65, Inc.
Membership Application Form
Name: ____________________________________________________________
Name of Business: ___________________________________________________
Mailing Address: _____________________________________________________
______________________________________________________
Street Address: ______________________________________________________
______________________________________________________
Phone: Fax: ___________________
E-mail: _________________________________________________
Web Address: ___________________________________________
Contact person(s) to receive information concerning meetings and events: __________________
Type of Membership:
1. Individual --- $25.00
2. Small business (5 employees or less) --- $75.00
3. Medium/large business (6 or more employed) --- $100.00
4. Non-profit and 501(c)3 organizations --- $75.00
5. Municipality (city, state or parish) or government agencies --- $75.00
Description of the business: __________________________________________
________________________________________________________________
Driving Directions to the business from U.S. Highway 65:
____________________
________________________________________________________________
Please print out
Membership Application and
return with your check or money order
payable to "LA Delta 65, Inc." and mail to the treasurer:
Kathy Nunnery, Treasurer
Louisiana Delta 65, Inc.
PO Box 431
Vidalia, LA 71373