LEXINGTON PLACE CIVIC CORPORATION

MEMBERSHIP FORM

DATE ________________                           

NAME___________________________________________________

ADDRESS________________________________________________

PHONE NUMBER______________   E-Mail Address_______________

PAID CASH_________         CHECK #________

MEMBERSHIP NUMBER_________  (leave blank)

$50.00 annually, make check payable to L.P.C.C. 

Mail to:  L.P.C.C. P.O.Box 872

            Chalmette, LA 70044