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.