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

__________________________________________________________________________________________Company Name Office Number

__________________________________________________________________________________________Name/Owner Year Company Established

__________________________________________________________________________________________Business Address

__________________________________________________________________________________________City/Parish/State/Zip

__________________________________________________________________________________________Business Phone Number / Cell Number / Fax Number

__________________________________________________________________________________________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