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                        THE LEELANAU COUNTY DEMOCRATIC PARTY
                                      MEMBERSHIP FORM

Name(s)__________________________________________________

Address (If applicable, include both street address and P.O. Box)

        _____________________________________________________

        _____________________________________________________

        City_____________________________ State_____Zip________

        Telephone__________Email_____________________________
              (LCDP does not release email addresses of its members)

* Occupation_________________Employer Name_________________

* Employer Address__________________________________________
                                  (*required by law)

Dues ($10/person/calendaryear)____________Donation___________
        (Dues and donations are not U.S. tax deductible)

Please make checks payable to: Leelanau County Democratic Party
        and mail to: Leelanau County Democratic Party
                             c/o Charles Godbout, Treasurer
                             P.O. Box 215, Empire, MI 49630

                     Check here if you wish to be added to our list
                     of volunteers