Membership Submission Form

Because to the low cost of membership and the high cost of online payment processing we request that you please send a check (made out to the Columbia Democratic Club) to...

* Indicates Required Field
Name*
Address*
Address
City*
State*
Zip*	(Exam. 21045 or 21045-0123)
Phone*	(Exam. 410-555-1212)
Fax	(Exam. 410-555-1212)
E-mail*
Yearly Membership Dues*	$30 Individual $15 Senior (65 and up) $15 Student $15 Persons w/Disabilities
Number of Additional Family Members ($15 each)
Additional Contribution
I would like to help: (check all that apply)
Work on a fundraiser
Put up window/lawn signs
Put bumper sticker on car
Help prepare mailings
Write or sign letters to the editor
Work at the polls on Election Day
Make phone calls
Work voter registration tables
Distribute Literature
Serve on a WHCDC committee
Please tell us about yourself
Interests
Other
Please send me your E-mail Newsletter	Yes  No