Member Application / Renewal with Options
  1. Fields with an asterisk (*) are required.

    Use this form ONLY if you wish to pay online now for your application.

    New members: fill in fields as needed.
    Renewing members: fill in any changes to current listing. If no changes are submitted your listing will be the same as last year.
  2. Company Name(*)
    Please type your full name.
  3. Contact name to be shone in guide(*)
    Please type your full name.
  4. Title
    Invalid Input
  5. Address (Street Number, Address, City, Zip)
    Invalid Input
  6. Phone
    Invalid Input (123-456-7890)
  7. Cell
    Invalid Input (123-456-7890)
  8. Fax
    Invalid Input (123-456-7890)
  9. E-mail
    Invalid email address.
  10. Website
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  11. Description about your organization (max 400 characters)
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  12. 0/400 characters used
  13. How long have you been in business providing this service/product?
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  14. Please list associations /organizations in which you hold memberships
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  15. LVAIP Referring Member(*)
    Invalid Input
  16. Business Reference 1 Name(*)
    Invalid Input
  17. Business Reference 1 Company(*)
    Invalid Input
  18. Business Reference 1 Address (Street Number, Address, City, Zip)(*)
    Invalid Input
  19. Business Reference 1 Phone(*)
    Invalid Input (123-456-7890)
  20. Business Reference 2 Name(*)
    Invalid Input
  21. Business Reference 2 Company(*)
    Invalid Input
  22. Business Reference 2 Address (Street Number, Address, City, Zip)(*)
    Invalid Input
  23. Business Reference 2 Phone(*)
    Invalid Input (123-456-7890)
  24. Comments
    Invalid Input
  25. Explain how your organization benefits seniors(*)
    Invalid Input
  26. What committees you would like to join or receive info:
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  27. Annual Membership dues: $145, $110 for Oct-Dec, $75 for Jan-Mar, $45 for Apr-Jun
    Membership provides one listing in the Annual Resource Guide and all other rights and privileges of membership.
  28. Member Dues
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  29. Total Price
    0 USD
  30. Please Note: You do not have to have a PayPal account to pay for your tickets.
    Paypal will accept your payment method without needing a PayPal account.

  31. Anti-Spam(*)
    Anti-Spam
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