Lake Madison Development Association

P.O. Box 296

Madison SD 57042-0296

MEMBERSHIP FORM

2010 Membership Dues  $25.00

Name of person(s) to be listed in Directory:  ______________________________________________________________________________

Mailing Address:   (Street Address)____________________________________________________________________

(City)___________________________________________, (State)__________(Zip Code)___________

 Phone number and e-mail for directory (optional):  (_________) ______________ E-mail:___________________________________________

____Dues $25.00

____Water Quality Contribution __________

                                                                                                            Total Enclosed: $_________________

Please make check payable to the Lake Madison Development Association and mail to the address at the top of the form.  Thank you.