Affiliate or Associate Membership Form

The membership application review process will take place between October 1 and April 30.

Today's Date
MM slash DD slash YYYY
Name of Nominee*
First Last
Membership Type*
Address of Nominee*
Street Address Address Line 2 City State ZIP Code
Email Address of Nominee*
Phone of Nominee*
University Attended*
Major*
Career Plans*
Employed By*
Employer Contact Info*
Other Employer*
Other Employer Contact Info*
Years in Current Profession*
Contributions to Louisiana Agriculture*
Years Attending LACA Annual Meeting (LATMC)*
Person Making Nomination*
First Last
Nominator's Address*
Street Address Address Line 2 City State ZIP Code
Nominator's Email*
Nominator's Phone*
Additional Information
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