Membership Form

C. G. JUNG SOCIETY OF LAFAYETTE, LOUISIANA
Website: cgjunglafayettela.org

Email: cgjungsocietylafayettela@cox.net

Phone: (337) 232-9914

MEMBERSHIP
September 2019 – August 2020

CHECK PAYMENT(S): CHECK ONE:

                     □ $100.00   - Benefactor                                          □ New
     □   $50.00    - Individual                                         □ Renewal
                     □ $25.00    -  Senior (65+)
       □   $25.00    - Student/Faculty (with ID)
□ $_____    - Donation

NAME: DATE:

ADDRESS:

            PHONE:

            E-MAIL:
                             □ “Check Here to Receive Email Announcements & Updates”

             AMOUNT ENCLOSED: CHECK NO.

MAIL CHECK WITH COMPLETED FORM TO:
C. G. Jung Society of Lafayette, LA

          Attn: Membership
              P.O. Box 683
               Abbeville, LA 70511

           OR

             PAY ONLINE WITH CREDIT/DEBIT CARD AT:
             https://www.cgjunglafayettela.org