Lafayette Penny Foundation, Inc. P.O. Box 884 Mayo, Florida 32066-0884

Membership Application or Renewal

Membership dues: $10.00 Annual

I support the purposes of the Lafayette Penny Foundation Inc and:

____ Apply for Membership
______ Renew my Membership

Date: __________________

Name: _______________________________________

Address: ______________________________________

City: ___________________ State: _____ Zip:_________

Telephone: ___________________________

Remarks:_________________________________________________________________________

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Signature: ____________________________________