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Agency/Society Membership Form

Society Name *

Address

City

State/Province

ZIP

Country

Tel

Fax

Website

Were you Recommended by a LCJE Member? If so, who?

First Recommendation

Second Recommendation

Please indicate your agreement with the following:

1
The Lausanne Covenant

2
The aims of the LCJE

3
Upon acceptance of our application we will comply with the dues requirement, as specified below.

Dues Table
What is the Annual income of your Society?

1
Less than US $50,000 - $200

2
Less than US $100,000 - $300

3
Less than US $500,000 - $500

4
Less than US $1,000,000 - $800

5
More than US $1,000,000 - $1000 per million but no more than $6,000

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