POA 2012 Membership Form
Please type in each section and print the completed form.
Either mail it to the address below or bring it to a Membership Meeting.

The POA
P.O. Box 1657
Lady Lake, FL 32158

New Member
Renewal



Number of People in Household:  

Name(s)(1):  
(Same Last Name)

Name(2):  
(Different Last Name)

Address:  

Village:  

City:     State:     Zip Code:  

Phone:       E-Mail:  
  (We respect your privacy: your E-mail address is for POA official use only)

1. New Membership/Renewal

Please enroll my membership in the POA at the Annual Rate of $10.00 per household. A check
payable to POA is enclosed. Memberships are for households and run annually from Jan.1st to Dec. 31st.

(Check the box below that applies)
  Please mail my Membership Card to me at the address above. I will include a stamped,
self-addressed envelope with this form and my check.
  Please hold my POA Membership Card for me to pick up at one of the monthly POA meetings.

2. Additional Contribution

Please accept my additional contribution to the POA in the following amount: $
Total Amount Due: $

Thank You for Your Support of the POA and your Generous Contribution.

Date Received (Official use only):  _________________
Fill in this form before printing.