VADETS

Virginia Association for Driver Education and Traffic Safety

MEMBERSHIP APPLICATION

Date: _____/_____/_____

CIRCLE ONLY ONE:       Active ($20:00)           Student ($5:00)

                                                      Life ($150)                  Corporate ($150)

(Please Print the Following Information)

Name_______________________________________________________________

Home Address________________________________________________________

City/State/Zip_________________________________________________________

School/Business_______________________________________________________

Home Phone________________________ Work Phone_______________________

E-mail_________________________________ Fax Number___________________

Please send check made payable to:                    VADETS

                                                                           C/O Joanne Burruss

                                                                            3783 Carr Lane

                                                                            Hayes, VA  23072