Friends of the Jim Lucas Checotah Public Library

Please print and complete this application

Return it with your dues payment to the circulation desk at the Jim Lucas Checotah Public Library
OR mail to
Jim Lucas Checotah Public Library
626 West Gentry
Checotah, OK 74426

 

________________________________

______________________________

___________

Last Name

First Name

Middle Initial

_______________________________________________________________________________

Street Address

__________________________

____________________________________

___________

City

State

Zip

_______________________________

_______________________________

Home Telephone

Alternate Phone

_______________________________________________________________________________

E-mail

_______________________________________________________________________________

Alternate E-mail Address

(Please print clearly in blue or black ink. Thank you.)

 

Type of Membership

Individual Yearly

$5.00

Family/Individual Lifetime

$50.00

Donation

$______

TOTAL

$______