Form Page: membership_form

Membership Application

Last Name:

First Name:

Email:

Phone:

Fax:

Date of birth:

Address:

Gender:

Male

Female

State:

Country:

Family Information

Relationship:

D.O.B:

Name:

Relationship:

Name:

D.O.B:

Relationship:

D.O.B:

Name:

Relationship:

D.O.B:

Name:

Relationship:

Name:

D.O.B:

My Family and I, names listed above would like to become a member of the Lao Asssociation of CT, Inc. and will comply with all existed By-Laws of the L.A.C. Attached is a membership fee $10.00/ year; for a total amount of:

Please make checks or money order pay to the order of the Lao Association of Connecticut, Inc., and mail to:

P.O. Box 330513
West Hartford, CT. 06133-0513

If you wish to pay with PayPal, please select "Donate" once the application has been submitted.

Please enter the code above in the box below.

Can't read the image? Please click here to refresh