Southern Leadership Summit

Member Application
Name: ____________________________________________________________
Street Address/PO Box: ______________________________________________
City: _____________________________

State: _____

Zip: _____________

Preferred Email Address: _____________________________________________

Phone #: _________________ Organization: _____________________________
Position ___________________________________________________________
What kind of membership are you interested in? __ Individual __ Organization
(All memberships are $150 and entitle one person for breakfast at each
meeting. Additional participants pay $10 for the meal)

Payment of $150 is due on January 25, 2016.

Please return this form to:
Lutheran Theological Southern Seminary
Attn: Darcie Jones
4201 N. Main Street
Columbia, SC 29203
Checks made payable to: LTSS