MLLA

7070 Terrell St

Waterford, MI 48329

First and Last Name ___________________________________________________

Additional Name (if applicable) ___________________________________________

Lake Address __________________________________________________________

Mailing Address _______________________________________________________

(if different from above)

Phone Number(s) ___________________________________________________________

E-mail Address ________________________________________________________

Membership Dues ($45 annually): _____________________

Invasive Species Fund Donation: _____________________

Fireworks Donation:                   _____________________

Total Enclosed:                                _____________________