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SCCAA
110 Fourth Street
PO BOX 129
D'Lo, Mississippi 39062

 MEMBERSHIP CARD -  enclosed is my tax deductible membership and/or contribution to help meet the needs of the South Central Community Action Agency, Inc.

Corporate Sponsor   $5,000   __________
Honorary Fellow       $2500    __________
Friends of SCCAA   $1,000     __________
Concerned Citizen    $500      __________
Associate Sponsor    $250     __________
My Contribution                   __________

Name:   ______________________________________

Address:  _____________________________________

City/State/Zip:   ________________________________

Phone:  ______________________________________

Email:  _______________________________________