Author: Lyn B

Please Complete the Following and
Return it With Your Payment:

Name: ________________________________________________________________
Address: ______________________________________________________________
City: ___________________________________ State: ____ Zip: ______________
Home Phone: ______________________ Work Phone: ______________________
Cell Phone: ________________________
Occupation: ___________________________________________________________
Birthday on the _________ day of ____________________ month.
Email: ________________________________________________________________
Who introduced you to this club? _________________________________________
What particular interests do you have? (circle)
Door to Door Fund-raisers Calling Voter Registration Fair Tent Poll Worker
Teen Age Republican Advisor Social Events Campaigns
What committees would you like to serve on? (circle)
Ways & Means Membership Social Program History Greeters Chaplain
Legislative By-laws Handbook Caring for America Literacy

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Dues Amounts:
Upon reaching 90 - life membership at no cost
Upon reaching 65—$20.00
Under 65 Years of age—$25.00
Associate Membership—$25.00
Please give completed form and payment to
Dori Howdieshell, Treasurer

By Lyn

Paid for by the Darke County Republican Women's Club, Treasurer Dori Howdieshell, 507 Wayne Avenue, Greenville, OH 45331