MEMBERSHIP/CONTRIBUTION FORM Please print, fill in and mail to:

Lynchburg Democratic Committee
PO Box 1363
Lynchburg VA 24505

Please print clearly: NAME(S)*__________________________________________________

ADDRESS*_____________________________________________________________________

CITY*___________________________________

STATE*___________ZIP*________________________

OCCUPATION*_________________________________________

EMPLOYER OR BUSINESS* ______________________________

CITY & STATE OF EMPLOYER OR BUSINESS* ______________________________________
* indicates required by state law

PHONE ________________ EMAIL________________________________________________

WILL YOU VOLUNTEER? _________ VOLUNTEER INTERESTS _________________________

Paid for and authorized by the Lynchburg Democratic Committee. Contributions are not tax deductible. Contributions of $100 or less per calendar year, or $8 per month, are NOT made public.

CIRCLE your contribution amount:   $8     $10     $25     $50     $100    Other $_________

[__] I enclose a check payable to "Lynchburg Democratic Committee"

[__] I authorize the Lynchburg Democratic Committee to bill my credit card for the amount above: (If billed to a credit card, an email address is required. Otherwise, it is optional.)

       CIRCLE one:   ONE-TIME     EVERY MONTH

       CIRCLE one:   VISA       MASTER CARD      DISCOVER      AMERICAN EXPRESS

       Card number ___________________________________Expiration____ / ____

       Name on card __________________________________

I am a US citizen or permanent resident. This contribution is made from my own funds.

Signature __________________________________ Date signed ________________________


This Web site is paid for and authorized by the Lynchburg Democratic Committee. Not authorized by any candidate.