Licking County Democratic Club Membership Form

Yes, I want to support Democratic efforts in Licking County. Count me in!

________Standard Membership: $25.00, with a $5.00 discount available for those paying prior to the March meeting.

________Associate Membership (non-voting): $25.00, with a $5.00 discount available for those paying prior to the March meeting - for those individuals who are not registered to vote in Licking County but want an active voice.

________Progressive Membership: $50.00 covers one (1) Standard or Associate membership and a ticket to the JJ Dinner.

________Student Membership: $5.00 with a valid student ID.

________ Yes, you may automatically place Democratic yard signs in my yard each year!

Please make check payable to Licking County Democratic Club.

Please print!

Name ________________________________________________________________

Address _______________________________________________________________

______________________________________________________________________

Email Address _________________________________________________________

Phone # ______________________________________________________________

Thank you! Please return this form along with your check to:

Ann Rader, Treasurer
Licking County Democratic Club
c/o Licking County Democratic Party
15 W. Church St.
Newark, Ohio 43055