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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)
   

Membership Dues are $10 per person per calendar year, January 1 through
December 31. Contribution are
not U.S. Tax deductible.

Your occupation and Employer information are required by State Law if the
total contributions per person including the biennial banquet in June and
other event equals or exceeds $100 in a calendar year.

       $10 ___  $20 ___ $25 ___ $50 ___ $100 ___ Other __________

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

           

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