SHREVEPORT LITTLE LEAGUE, INC.

2459 EAST 70TH STREET, SUITE 5

SHREVEPORT, LA 71105

(318) 798-7972

NAME: (No Nicknames Please)____________________________________________

Address_____________________________Email Address_______________________

City__________________________________________State________Zip__________

Contact Phone Number(s) _________________________________________________

Social Security Number:_________________________

Please fill out and print this form and return it to the LITTLE LEAGUE OFFICE by mailing it to the address above. It is IMPORTANT and NECESSARY for this information to be in the office for you to receive your next pay check. If you should move during the year, please inform the office.

THANK YOU