Please print this page and fill in the items below.     Title  ______  * First Name  ____________________________________  * Last Name  ____________________________________  * Address:  ____________________________________     Address 2  ____________________________________  * City  ____________________________________  * State  ____________________________________   * Zip Code  ___________     Home Phone  _________________     Bus.Phone  _________________     FAX Number  _________________  * Email  ____________________________________ *  Entry Required Circle:        $50 Individual        $75 Household        $40 Student Please enclose with your check (to LWV Polk County) and mail to: LWV Polk County P.O. Box 934 Lakeland, FL  33802