Los Angeles Republican Clubs United
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* For BCR Use Only *
Open to Republicans Only & Republicans guest(s) of members Only!
BEACH CITIES REPUBLICANS ONLINE MEMBERSHIP APPLICATION
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Indicates required field
Date of Application MM/DD/YR
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Check one:
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Mr.
Ms.
Mrs.
Miss
Dr.
Hon.
Name
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First
Last
Home Address
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Line 1
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City
State
Zip Code
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Employer
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Job Title
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Cell Phone
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Home Phone
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Work Phone
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Current /prior offices held (dates)
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Email #1
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Choose Any (Check One)
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I am a registered Republican
I authorize the BCR to disclose my membership
Digitial Signature
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Date MM/DD/YR
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Spouse:
Check one
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Mr.
Ms.
Ms.
Miss
Dr.
Hon.
Spouse Name
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First
Last
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Spouse Employer
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Spouse Job Title
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Email #2 (Spouse)
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Spouse (Choose Any) (Couples Only)
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I am a registered Republican
I authorize the BCR to disclose my membership
Digital Signature (Spouse)
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Date MM/DD/YR
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Membership: (Choose One)
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NEW
RENEWAL
GIFT
Level of Membership: (Check) (Choose One)
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Student $10.00 (Valid Current ID Required)
Regular Member $25.00
Couples Membership $40.00
Because I Can Member $50.00
Executive Member $100.00
Club Sponsor $500.00
Leadership Circle (Lifetime) $1000.00
How did you hear about us?
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Interests: (check as many as you want)
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Voter Registration
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Other
If you'd check other; please write in reponse:
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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
