CENTRAL REPUBLICAN WOMEN’S CLUB

                                    MEMBERSHIP APPLICATION/RENEWAL FORM

                                                                                                            Date:  __________________

Name: _________________________________________________________________

             Title                 First                              Last                                          Spouse’s First Name

Mailing Address: _________________________________________________________

_______________________________________________________________________

City                                          State                                        ZIP Code+4

Phone:_________________________________________________________________

                        Home                                       Office                                       FAX

E-mail: _________________________________________________________________

I wish to receive the Club’s monthly newsletter via e-mail             Yes     No 

Political Information:  Congressional District:________  

  Legislative District: __________Precinct: _____________________

                                      Precinct Committeeman:  Yes     No 

Referred By: __________________________________

Dues: (Check applicable membership level)                   Active Member:                $25.00

      Associate Member            $10.00

(Associate membership is available to any registered Republican who is a member of another AFRW

club, lives out of state, or is a man.) 

Please indicate your primary AFRW Club if joining as an Associate: __________________________

Send check payable to Central Republican Women’s Club with completed form to:

Mary Lee DeCoster