GET INVOLVED

REPUBLICAN CLUB OF LAKELAND

Membership Application

___I want to join the Republican Club of Lakeland.

___I certify that I am a registered Republican.

Dues for membership in the Republican Club of Lakeland are payable

annually in January.

Levels of membership and annual dues in the Club are (1)$100 for a
Bull Elephant Sponsor, (2)$50 for a Sponsor, and (3)$25 for regular
membership. Please mark the membership level you choose.

From now to end of the 2010-Year

___(1) $ 100.00 Bull Elephant Sponsorship, Dues, The Trumpeter
___(2) $ 50.00 Sponsorship, Dues, The Trumpeter
___(3) $ 25.00 Dues and The Trumpeter

Make your check payable to the Republican Club of Lakeland and mail
to:

Richard Derk, Treasurer

1555 Williamsburg Square
Lakeland, FL 33803

Thanks for becoming a member. We appreciate your help and support.

 GET INVOLVED

REPUBLICAN CLUB OF LAKELAND

Please complete the following information for our Club membership

records. Please Print Clearly

Today’s Date_______________________________________________

Last Name _________________________________________________

First Name _________________________________________________

Nickname _________________________________________________

Address ___________________________________________________

City ______________________________________________________

State____________________ Zip_______________________________

Phone-work ________________________________________________

Phone-home _______________________________________________

Phone-cell ______________________________ Precinct #__________

E-mail ____________________________________________________

Spouse’s Name _____________________________________________

“The Fate of good men (and women)

who refuse to become involved in politics
is to be ruled by evil men.”
Edmund Burke