(Please Print)

Name:

Address:

City:                                                                                                   State:                  Zip:

Home Phone:    

Work Phone:

Fax:  

Email:

Type of Membership:  □New $30   □Renewal $30    □Associate $30    □Sponsor $30 **

Registered Republican:  □Yes     □No   (Must be a Registered Republican to be a member.)

Regular Member in another Federated Club:   □Yes        □No               **(include business card)

      If yes, name of other Club: ________________________________________________

Area(s) of Interest (please check all that apply):

□ Aging/Medicare

□ Family Issues

□ Opposition Research

□ Agriculture

□ Legislation

□ Telephone Committee

□ Americanism

□ Meeting Hostess/Setup

□ Voter Registration

□ Campaign/Headquarters

□ Membership

□ Ways & Means

□ Education

□ Newsletter

□ Other:

Comments:

Make checks payable to SYRWF (Sutter-Yuba Republican Women Federated)

Send this form and check to:    

SYRWF Membership

P.O. Box 791

Yuba City, CA  95992