PEOPLE OF SUBSTANCE, INC.
1436 North Villere Street
New Orleans, LA 70116
MEMBERSHIP APPLICATION

Name:_____________________________

Address___________________________

C/S/Z:____________________________

Phone:____________________________

Email:____________________________


Employment
Employer:____________________________

Position:____________________________


Emergency Contact Information:
Name:_____________________________

Number:___________________________


Signature__________________________

Date:______________________________

Print this page and fax to
Darrell K. Sims at 504-324-0947
or
Mail it to the above address.
.