2021 LoW Registration/Renewal Form

New/Renewal Membership

Complete the form below to become or renew your LoW Membership
Membership *

New Member Renewal Rejoining Member(membership has expired)
Refer by (So we can say Thank You)
Name *

First Name Last Name
Name & State for Badge
Name & State
E-mail *
Birth Month/Year (Optional)
Permanent Mailing Address: *

Street Address

City State

Zip Code
Phone Number

Area Code Phone Number
Phone Number *

Area Code Phone Number
Gender (optional)

Male Female
Occupation (If retired-previous) Optional
Do you wish your above profile to be seen by other members in the online directory? (Note: ONLY active LOW members have access to the directory)

Yes No
In which state (or Full-Time) should you appear in directory-Note: ONLY LOW Members can access the directory
Option: Emergency Contact Information for Back of your badge. ($2.00 additional cost. Be sure to check box in Rates Menu at the bottom of page)
Emergency Contact

Name Phone Number
Membership Rules
MEMBERSHIP REQUIREMENT

To become a member of Loners on Wheels, you must be legally single. By checking below, you agree to the Simple Statement and is a testament to the fact.
If you should marry while being a member, your membership is automatically terminated.

When attending official LoW events, you must conduct yourself as a single individual at all times.

SIMPLE STATEMENT
I understand that the LoW directory is to be held confidential, and that I will never use it, or knowingly allow it to be used, for other than my personal exclusive use.

• Thank you!
*

I have read, understood, and accepted the rules for membership.
Check the appropriate boxes below and then click the submit buttom at the bottom to enter your payment information. Credit card processing fees have been included in the totals for your convenience.
Membership *
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1 Year Membership $ 52.00

2 Year Membership $ 92.00

3 Year Membership $ 142.00

5 Year Membership $ 237.00

Total $ 0.00
Should be Empty:

New/Renewal Membership

Membership Rules