Membership Form

To register by mail, print and mail this application.

To register electronically, and pay by credit card, please complete the following:

 

• Name *
   
• Company *
   
• Address *
   
• City *
   
• State *
   
• County *
   
• Zip Code *
   
• Phone Number *
   
• Email *
   
  Confirm Email

   
• Web Site *
  Website will be listed on "Find a Professional" section of the LMA Site.
   
• Region
  North-West

  North-Central

  North-East

  Central

  East-Central

  West-Central

  South-West

  South-East

   
   
• Please Check All That Apply
  Yes, I have liability insurance.

  Yes, I have workers' comp insurance.

  I am exempt from the above coverages.

  Yes, I hold a pesticide license.

   
   
• Pesticide License Category
   
• License #
   
• How many full-time employees including yourself
   
• Have you or your company ever been a LMA Member?
  Yes

  No

   
   
• If yes, when and how was the membership listed?