LOUISIANA PUBLIC TAG ASSOCIATION

MEMBERSHIP APPLICATION

INSTRUCTIONS: Please provide all of the information requested and mail the completed application to the LPTA at the address shown below along with your remittance. Incomplete applications will be returned. Your payment must be included with this application in order to be processed.

MEMBERSHIP IN LPTA IS INDIVIDUAL AND NOT TRANSFERRABLE FROM ONE PERSON TO ANOTHER

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Company Name Office Number

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Name/Owner Year Company Established

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Business Address

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City/Parish/State/Zip

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Business Phone Number / Cell Number / Fax Number

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Email Address (Please Print Legibly)

Annual Membership Dues are $1,200.00

Please check one of the following payment methods:

_____ Monthly ($100) _____ Semi-Annual ($600)

_____ Quarterly ($300) _____ Annual ($1,200)

Dues are non-refundable. All memberships will expire on December 31.
New Members whose application Received during a fiscal year rates will be prorated accordingly.
Members whose dues are not paid by March 15^th shall be automatically dropped from membership.

P. O. Box 148

Sulphur, LA 70664

(337) 626-2700