Membership Application

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* For BCR Use Only *

Open to Republicans Only & Republicans guest(s) of members Only!

BEACH CITIES REPUBLICANS ONLINE MEMBERSHIP APPLICATION

* Indicates required field

Date of Application MM/DD/YR *

Check one: *

Mr. Ms. Mrs. Miss Dr. Hon.

Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer *

Job Title *

Cell Phone *

Home Phone *

Work Phone *

Current /prior offices held (dates) *

Email #1 *

Choose Any (Check One) *

I am a registered Republican I authorize the BCR to disclose my membership

Digitial Signature *

Date MM/DD/YR *

Spouse:

Check one *

Mr. Ms. Ms. Miss Dr. Hon.

Spouse Name *

First

Last

[object Object]

Spouse Employer *

Spouse Job Title *

Email #2 (Spouse) *

Spouse (Choose Any) (Couples Only) *

I am a registered Republican I authorize the BCR to disclose my membership

Digital Signature (Spouse) *

Date MM/DD/YR *

Membership: (Choose One) *

NEW RENEWAL GIFT

Level of Membership: (Check) (Choose One) *

Student $10.00 (Valid Current ID Required) Regular Individual $25.00 Couples $40.00 Because I Can (Individual) $50.00 Executive (Individual) $100.00 Club Sponsor (Individual) $500.00 Leadership Circle (Individual) $1000.00

How did you hear about us? *

Friend Email Website Newspaper

Interests: (check as many as you want) *

Voter Registration Online/digital/social media Events/rallies/protests Club leadership Walk precients Letters to the editor Fundraising Run for elective office Phone calls/phone banks School/youth programs Technology/database Other

If you'd check other; please write in reponse: *

Please make check to Beach Cities Republicans / Contributions NOT deductible for income tax purposes.
Please print this form with payment and mail to:
Peter Michel
Beach Cities Republicans
Attn: Membership Dues
PO Box 1043
Palos Verdes Estates, CA 90274-7843

Submit Membership Application