MEMBERSHIP/CONTRIBUTION FORM Please print, fill in and mail to:
Lynchburg Democratic Committee
PO Box 1363
Lynchburg VA 24505
Please print clearly: NAME(S)*__________________________________________________
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.