HURON COUNTY REPUBLICAN WOMEN'S CLUB

2012 MEMBERSHIP FORM

QUESTIONS? Call our Membership Chairman, Patti Patusky, at 419-668-3299.

On the web at http://huroncountyrepublicanparty.com/

Facebook page, “Huron County Republican Women's Club”

Make checks payable to HCRWC.

MAIL TO: HCRWC, PO Box 316, Norwalk, OH 44857

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HURON COUNTY REPUBLICAN WOMEN'S CLUB 2011 MEMBERSHIP FORM

HOW MANY AMT.

Patrons More than $15.00 per year _____ x _____ = ______

Women (of any age) $15.00 per year _____ x 15.00 = ______

* Associates (Men) $15.00 per year _____ x 15.00 = ______

PLEASE PRINT Total Enclosed = ______ Ck # _____

Name(s) ______________________________________________________________________________

Address________________________________________City____________________ Zip ____________

Phone ____________________ FAX ________________ E-MAIL ________________________________

Note: All communication will be by email unless an email address is not provided.

Please use reverse side to list full names and addresses of additional members using this form.