REPUBLICAN PARTY OF CLARK COUNTY MEMBERSHIP APPLICATION

_____Membership Renewal ______New Member ______Change of Address

Suggested Annual Membership Dues; January 1 through December 31

_____$15 Individual _____$25 Couple _____$25 Associate Member (non resident)

__________Amount Paid

Name________________________________________________________________

Address_______________________________________________________________

City _________________________________State__________ Zip Code___________

Home Phone ______________Work Phone ______________ Email________________

I affirm that I am eligible to vote in any national or state election, and believe in the objectives, purposes and principles of the Republican Party; and will preserve our Republican form of government as created under the Constitution of the United States and the Constitution of Wisconsin.

Signed_______________________________________________Date______________

Make checks payable to:

Republican Party Clark County

Send to; P.O. Box 183, Neillsville, Wi. 54456

Count on me to help with:

_____membership _____phone calls ____ yard signs

_____mailings _____fair booth ____fund raiser

_____special events _____other ______________

Optional: State law requires that we ask your occupation and employer’s name and address, if your contributions total $100 or more in a year.

Occupation_________________Employer_______________________________

Employer’s Address__________________________________________________

Authorized and paid for by Republican Party Clark County, Sandy Luedke, Treasurer