Washington Affiliate Membership Application

I hereby apply for Affiliate Membership in the Lewis-Clark Association of Realtors and will provide my credit card information below to be charged 150.00, which represents Washington affiliate dues. My membership will be listed in the Association Roster as follows:

Designated Member:*

Company Name:*

Address*

Street Address City State Zip Code

Phone*

Fax

Email*

Web Site Address:

Types of Products/Services:*

I agree that if accepted into membership I shall pay the annual dues of $125.00 (or as amended). Applicant will be billed at the beginning of each new calendar year.

I authorize LCAR to charge my credit card for the following amount*

This payment is for...*

Credit Card Type*

Visa

MC

American Express

Discover

Credit Card Number*

Expiration Date*

CVC Code*

Electronic Signature:*

Today's Date:*