Print this Form and mail with your Check or Money Order to

LAKE CHAMPLAIN WALLEYE ASSOCIATION
P.O. Box 104
SWANTON VT 05488

New____   Renewal ______  Membership Number____________   (L.C.W.A will assign if new)

Name ____________________________________________________________________

Street_____________________________________________________________________

Town________________________________________ State______    Zip Code__________

Telephone __________________________                                Date_____________________

Email Address ______________________________________________________________

____ I would like to be contacted to take part in LCWA activities

Regular Membership - :$10.00
Junior (Under 15 years) - :$5.00
Family Membership - :$15.00 (Spouse and Children under 15 years of age)
Multi Membership (3 years) - :$25.00
Multi Membership (5 years) - :$40.00
Sponsor Membership- :$100.00
Benefactor Membership - :$500.00

Enclosed For Membership $________________    Donation for Projects $________________

Please list eligible names for family membership