Name______________________________________________________
Address____________________________
City___________________________
State________
Zip__________
Phone_____._____.______
Precinct #________________________________________
E-Mail ____________________________@__________________
Membership
Type:
□ $15.00
Individual □ $25.00 Family
□
$5.00 Students and Senior Citizen
□ $15.00 Associate Members (Non Voting membership
reserved for office holders and candidates)
□______________________ Additional Contribution
Helpful Skills:
□ Data Entry/Computer Skills □ Mailing,
Stuffing Envelopes
□ Phone Banking
□ Pricinct Chair Comments:______________________________________________________________________
Date received: __________________________________ (To be filled in by
treasurer)
