LOUISIANA CONFERENCE ON WATER SUPPLY, SEWERAGE, AND INDUSTRIAL WASTES, INC.

MEMBERSHIP APPLICATION

DATE                                 

NAME                                                                                                                                         

ADDRESS                                                 CITY/STATE                              ZIP                     

PHONE                                  SOCIAL SECURITY NUMBER                                             

EMPLOYER                                                                                                                               

ADDRESS                                                 CITY/STATE                              ZIP                     

Are you a member of a regional Association                     Yes                      No

Check one:                Northwest                  Northeast                  Central                  Southwest

                                      Capital                South Central                Southeast                Lake

Are you a member of AWWA                     Yes                 No

Membership Fee is $10.00 Annually

Please make check payable to : Louisiana Conference

Remit to: Louisiana Conference

                P.O. Box 1154

                Minden, LA 71058-1154