Please provide the following information:

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip Code
Home Phone
FAX
E-mail

Please Select Your Desired Membership Type:

Regular Membership - $ 15.00
Family Membership - $25.00
Texas Democratic Women Membership - $15.00 (make Check        --- Payable to Texas Democratic Women of Van Zandt Co.)
Associate Member - $10.00

I would also like to make an additional contribution:

Sorry, not able to contribute at this time
$ 10.00
$ 25.00
$ 50.00

Please print out this completed form and mail with your check or money order to:

V Z County Democratic Party     OR     Van Zandt County T.D.W.

     James Foreman, Chair                  Dorine Cunningham, President

           903 VZCR 2128                          706 VZCR 3209
         Wills Point, TX 75169                 Wills Point, TX 75169