Membership Enrollment

You may either download the Adobe Acrobat enrollment form to become a member or complete the form below. To use the downloadable form, you will need to have the Adobe Reader installed. If you do not have it, you can download it for free from  Adobe.

• F-48a: Membership Application

Online Membership Enrollment & Renewal of Annual Dues

If this is your first time becoming a member, you may be contacted for further information.
Please provide the following information: ( Red indicates a required field)

Membership Renewal	New Application (a one-time additional $20 registration fee will apply)
First Name
Last Name
Middle Initial
Membership # (if already a member)
Date & Place of Birth
Occupation
Children under 18 (name and date of birth)
Mailing Address
Address (line 2)
City
State/Province
Zip/Postal Code
Country
Telephone
E-Mail Address
Family members who are LRFA members (name and membership number):

I would like to receive information about:
Medicare Supplemental Plan
Independent Prescription Drug Plan
Health Care Plan
Supplemental Health Care Plan
Emergency Accident & Health Benefit Plan For Visitors From Abroad
International Travel Plan
Mortuary Benefits Plan

Please forward all information in
Latvian
English

Questions and Comments:

Your Signature:
The above information is true to the best of my knowledge. I support the principles and work of LRFA.