First Name
Last Name

2010-2011 LSPAA Membership                                  $75.00
LSPAA Scholarship fund donation                                                  $   

Advertisement in the directory:
$250 full page ad                                      $
$75    business card size ad                        $
TOTAL AMOUNT DUE (Required):               $

Payment Informatiom:
   Pay via PayPal (click the link at the bottom of this form)
   I will pay via check
                 from me personally
                 from my business/employer

Make check payable to :
         Leadership St Pete Alumni Association
         LSPAA Tax ID #59177846
         Mail to: LSPAA
         P.O. Box 1097
         St Petersburg, FL 33731-1097
   _______________________________________________
Work, home or both? If you are providing two forms of contacts information, please specify which (or both) you would like published in the new LSPAA Membership Directory. Thank you!

 Contact information has not changed within last year (go directly to the "submit" button at the bottom to pay) 

Salutation (Mr., Mrs., Ms., Dr., etc.)
First Name   MI
Last Name
Suffix
Preferred Name (Nickname)
LSP Class Year

Work Information (Publish in directory  Yes  No)

Company 
Title           
Website   
Line of Business (e.g. Accounting)
                
Work Address:
Street       
Suite/appt  
City           
State                           Zip   
Work Email
Work Ph        ext.
Work Fax      ext.

Home Information (Publish in directory  Yes  No)

Home Address
Suite/Appt        
City                  
State                
Zip Code          
Home Email      
Home Phone    
Home Fax        

Personal Info (Publish in directory     Yes  No)

Cell Phone     
Spouse         

Preferences:
(Please select one option for each)

I prefer to receive LSPAA E-MAIL correspondence at my:
 Work E-MAIL address
 Home E-MAIL address

I prefer to receive LSPAA MAILING correspondence at my:
 Work address
 Home address

Please contact me for the following:
 Offer a business discount to LSPAA members (discounts are listed on www.lspaa.com/membership.html  All paid members will receive a LSPAA member card with their membership directory).
 Would like to nominate someone for the LSPAA award (see Award Recipient section of the LSPAA website).

  Note: we will contact you to provide us with more information about the nominee.
 Place a full-page business ad in the membership directory and on the LSPAA website for $250.***
 Place a business card-size ad in the membership directory and on the LSPAA website for $75.***
 Interested in serving on the LSPAA Board of directors.
 Interested in helping with LSPAA activities and working on a committee.

*** If you are placing an ad, an LSPAA Board Member will contact you.

Additional Comments:
If you have any questions about your member profile, please email Alison Barlow at membership@lspaa.com