CAPTAIN___________ MATE_________

NAME_______________________________________

ADDRESS ___________________________________

CITY_________________________________________

STATE__________________ ZIP______________

EMAIL_______________________________________

HOME PHONE NUMBER_______________________

CELL PHONE NUMBER_________________________

DATE OF BIRTH________________________

SOCIAL SECURITY NUMBER__________________

USCG LICENSE # ____________________________

EXPIRATION DATE_____________

Are you currently a member of a maritime drug consortium?

Yes ______ No________

OH or Documentation #’s________________________

SIGN ________________________________________

DATE ________________

$ 45. DUES ARE EFFECTIVE
JANUARY 1 to DECEMBER 31 of current year

Make checks payable to LECBA Drug Program

mail to:
LECBA Drug Program
c/o Sandee Abele
245 N Worthy
Lakeside, OH 43440

Questions call Sandee Abele

(419) 732-2670

email: saja@cros.net