Contact Listing Only Information Form
Submit Electronically (if CC Pd) OR Mail-In with Check only
Credit Card payers - Once you have paid through our Shopping Cart, you still have to fill out this Information Form and
click the "submit Electronically (if cC Paid)" button below to Electronically send us your info.
Check By Mail Payers - If you are paying by check, you must fill out the information, print the form and send it along with your check via USPS mail
to Larry larsen, 2640 elizabeth place, lakeland, fl 33812.
All Supporting Membership Dues are for the full Calendar year (e.g. 2016, 2017). If you sign up mid
-year, please call for the additional prorated dues cost in order to make your check in the correct amount. There is a one year minimum for PBA Dues.
We are requesting the following data format for directory consistency: