Name*:

Address*:

Home Phone**: Work Phone**: Mobile**:

E-Mail*:

Occupation or Profession:

I am a registered Democrat in (name of town or city)

I am interested in working on one or more of the following committees:

Fundraising Campaign Membership Newsletter

Public Relations Legislative Voter Registration

Candidate Endorsement Youth Outreach

Other

I am available: Weekdays; Evenings; Weekends

MEMBERSHIP TYPE* (please select one) Regular (Orange County Resident) - $20 annual dues Ex Officio (Non-resident) - $20 annual dues Senior Citizen (age 60 and over) - $15 annual dues Full-time College Student - $15 annual dues Full-time High School Student - Free (please select one) New Member Renewal

*required field
**you must provide at least one phone number