Membership Form

Greene County Democratic Women

Membership Application

Name ______________________________________________________________

Street ______________________________________________________________

City ______________________________________________________________

State ____________________________ Zip_____________________________

Phone _____________________________________________________________

E Mail ______________________________________________________________

Voting Precinct ____________________________________________________

Please indicate if you would prefer to receive your notices via e-mail instead of the U.S. Postal Service

_____ Yes (this saves trees and postage)

_____ No

Enclosed please find:

$________ membership fee ($5)

$________donation

$________total

Please make checks payable to Greene County Federation of Democratic Women and mail with application to:

Helene Dulaney, 2624 Smith Creek Road, Waynesburg PA 15370