Check One: ☐Initial Registration ☐Renewal (due 7/1 annually) Date: Click here to enter a date.

NAME OF LOCAL/STATE LEAGUE: Click here to enter text.

OFFICE Address: Click here to enter text. City: Click here to enter text. State: Choose an item. Zip: Click here to enter text.

OFFICE or MAIN CONTACT Email: Click here to enter text. Phone: Click here to enter text.

LOCAL LEAGUES ONLY - Number of Members as of January 31 (this year): Click here to enter text.

YOUR CONTACTS: Please indicate the person(s) from your LWV to whom ILO information is to be sent {we have space for up to 3 here, but you can send us more information by email}

Name: Click here to enter text.

Street: Click here to enter text.

City: Click here to enter text. State: Choose an item. Zip: Click here to enter text. Phone: Click here to enter text.

Email: Click here to enter text.

Communications (check one or more):

Newsletters ☐ Program/Annual Mtg Info ☐ Membership/Renewal ☐

Name: Click here to enter text.

Street: Click here to enter text.

City: Click here to enter text. State: Choose an item. Zip: Click here to enter text. Phone: Click here to enter text.

Email: Click here to enter text.

Communications (check one or more):

Newsletters ☐ Program/Annual Mtg Info ☐ Membership/Renewal ☐

Name: Click here to enter text.

Street: Click here to enter text.

City: Click here to enter text. State: Choose an item. Zip: Click here to enter text. Phone: Click here to enter text.

Email: Click here to enter text.

Communications (check one or more):

Newsletters ☐ Program/Annual Mtg Info ☐ Membership/Renewal ☐

Please Send your completed form and check for $25 (payable to LWV UMRR ILO) to:

LWV Upper Mississippi River Region ILO

c/o Jeri McGinley

Office Use Only: Date Rec’d: ____________ Ck: __________ Date to Membership: ____________ 516 Sunrise Avenue

Stevens Point, WI 54481