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