First Name_________________________________________________________________________

 

Last

Name_________________________________________________________________________

 

Adress________________________________________________________________________

 

City____________________________State_________________________Zip_______________

 

Home Phone _____________

E-Mail __________________

Employer_______________________________________

Occupation__________________________

 

 

Sustaining Membership-----$10.00 a month or $120.00 a Year (.33 a day)

$40.00 Savings for you and your spouse if Paid in full----$200.00 Yearly

$20.00 Saving for you (single person) if Paid in Full------ $100.00 Yearly

 

THANK YOU FOR SUPPORTING THE DEMOCRATIC PARTY!!!