* MEMBERSHIP FORM *

NAME(S):
   
ADDRESS:
 
HOME PHONE:
WORK PHONE:
FAX NUMBER:
E-MAIL:
Yes, I am a registered Republican
Yes, I would be interested in participating in election campaign activities (i.e., walk precincts, prepare mailings, make phone calls, etc.).
Yes, I would be interested in helping on a Cerritos Republican Club Committee (ex. "Fourth of July booth," Student Oratorical Presentation, Rummage Sale, etc.).

ANNUAL MEMBERSHIP DUES:

Select your desired membership.

Single: $15
Couple: $25
Student: $10
Senior Citizen (60+): $10
Patron: $100
Patron: $250
Statesman: $500

When joining on-line: The Cerritos Republican Club will send you your first issue of The Local Republican newsletter, confirmation of receipt of this form, and a bill for the appropriate dues amount. 

Any comments???