Membership Application

 HAMPSHIRE COUNTY DEMOCRATIC CLUB
  P.O. Box 476
  Augusta, WV  26704
 
 MEMBERSHIP APPLICATION  
 Membership is open to Hampshire County registered Democrats, without limitation, upon payment of their annual dues.  Associate   membership, without voting privileges, is open to all persons, 16 years of age or older, upon payment of their annual dues. 
    
       Annual Dues Schedule (please check type of membership desired)

             ____    Single Membership                    $20.00
  
             ____  Household Membership                   $30.00 (submit
                                                a form for each person)
    
             ____  Associate Membership                  $10.00
    
              
 Name ________________________________________________________________________
    
   Mailing Address_________________________________________________________________
    
   City   ___________________________ State _____________  Zip Code______________
    
   Voting Precinct Number ___________  Polling   Location _____________________
    
   Phone ____________(home)____________(work) _____________(cell)  Email__________________
    
Please print out form, complete, and mail with your check for dues payable to Hampshire County Democratic Club, P.O. Box 476, Augusta, WV  26704.

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