2006-2008 ILDA Membership Enrollment form

Please fill in the information needed, print this form to your printer, make check payable to The ILDA Treasurer and mail form & payment to: John Krause, ILDA Treasurer, 9905 Madison St NE, Blaine, MN 55434.

Type of Membership (please check one) Active Associate Supporting

Your membership due $20.00	$
Spouse membership due $20.00 (if applicable)	$
Your God's 1000 Club, add $20.00 (optional)	$
Spouse God's 1000 Club, add $20.00 (optional)	$
Totals	$

Mr Mrs Ms Miss Rev First name Last name

Subtitle

Spouse's full name

Street address Apt #

City State/Province

Zip + four Country

Phone (tty or voice?) Fax

E-mail

Thank you for your support!