DRUG CONSORTIUM APPLICATION 2009 CAPTAIN___________ MATE_________
NAME_______________________________________
ADDRESS ___________________________________
STATE__________________ ZIP___________
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
