Blue Chip Young Republicans Membership/Renewal Application
Name:
________________________________________________________________________________________________
(Last)
(First)
(M.I.)
Address:
________________________________________________________________________________________________
(Number)
(Street)
(City)
(ST)
(ZIP)
Phone Number:
Home ( )___________________________
Business ( )____________________________
E-Mail:_______________________________________________________________
Date of Birth:________________________________________
Your
Signature:______________________________________________________________________________
Date:___________________________________________
Type of membership:
Standard
_______$10.00
If you have the means, please consider contributing at a higher level:
Patron _______$50.00
William Howard Taft Club _______$100.00
Lincoln Club _______$250.00
Reagan Contributor _______$500.00
If new, how did you hear of the Blue Chip Young Republicans?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you have any prior political experience?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Note: The Blue Chip YRs use the information from this form for Club purposes only. This information is shared with only the Ohio and National Young Republican Organizations.
Mail to: Blue Chip Young Republicans
700 Walnut Street - Suite 309
Cincinnati, OH 45202
Copyright © 2006 [Blue Chip Young Republicans]-All rights reserved.