2011 Membership Application Form
  • Each married child needs to fill out a separate form.
    		•
  • Make Check Payable to: LPS of USA
    		•
  • Change of Address
    		•
  • Enclose $60.00 per form for membership fee for one year or $100.00 for 2 years
    		•
  • Print Your old Address
    		•
  • OR $1001.00 for LifeTime Membership
        
  • New Member
    		•  Mail to: LPS of USA
  • Life Member
    		•  716 Sweetwater Circle,Old Hickory TN 37138-2063
  • Membership Renewal
    		•  Tel:615-712-6199
    Fax:615-873-4650
       
    APPLICATION INFORMATION SPOUSE INFORMATION
     
      First Name :     First Name :
               
      Last Name :     Last Name :
               
      Fathers Name :     Fathers Name :
               
      Fathers Middle Name :     Fathers Middle Name :
               
      Village :     Village :
      New Village
    (Please Specify) :    		     New Village
    (Please Specify) :
               
               
               
      Mothers Name :     Mothers Name :
               
      Mothers Middle Name :     Mothers Middle Name :  
               
      Mothers Fathers Middle Name :     Mothers Fathers Middle Name :
               
      Mothers Village :     Mothers Village :
      New Village
    (Please Specify) :    		     New Village
    (Please Specify) :
               
               
               
      Name Of Business :     Profession :
               
      Home Address :     City :
               
      State :     Zip :
      New State
    (Please Specify) :    		        
      Phone :     Work Phone :
               
      Fax :     Mail :
               
       
    Unmarried Children
    First Name Only
    Date of Birth
    Month/Year
    Unmarried Children
    First Name Only
    Date of Birth
    Month/Year
    1.    4.    
    2.     5.    
    3.     6.    
       
    Married Children First Name Only
    1. 2.  3. 
    4.  5.  6. 
       
    Payment Option: Credit Card:
       
    Credit Card # CCV No
       
    Name on the CC EXP:
       
    Amount Authorize: $