Billing Information

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Lake County Port Authority Membership Drive Billing Request

Please bill me for the Lake County Port Authority Membership Drive on (month/day) _______________for the following membership:

Executive $_______________ Corporate $________________ Member $_______________
(Please fill in the amount- See Fee Schedule)

NAME:_____________________________________________________________________________

COMPANY:_________________________________________________________________________

ADDRESS:__________________________________________________________________________

CITY:_____________________________________________ STATE: ___________ ZIP: __________

PHONE: __________________________________ FAX: ____________________________________

E-MAIL: __________________________________

Mail request to:
Lake County Port Authority
One Victoria Place, Suite 265A
Painesville, Ohio 44077

- OR -

Fax request to:
440-357-2296