* MEMBERSHIP APPLICATION *

You must be registered as a Republican voter to join the Cerritos Republican Club. If you would like to join our club, please fill out the application below and print it. Read instructions below to mail application and check.

* required field
Full Name:*Second Person:
Street Address:*
City/Zip:*
Phone:*
Email Address:*Second Email:
Do not print my phone number in the CRC directory.
Do not print my(our) email address(es) in the CRC directory.

Members will receive emails from the Cerritos Republican Club and other Republican organizations.
I(We) understand that my(our) email address(es) will be hidden from other recipients of the emails.
I(We) can visit http://www.cerritos-republican.org for Club updates and links to other conservative websites.

These are the annual memberships levels which are available. I would like to join as:
$500 Statesman $250 Patriot $100 Patron $40 Couple/Family $25 Single
Birthdate to verify Party registration (MM/DD/YYYY)://*
Second Person Birthdate (MM/DD/YYYY)://
Sign the printed form. Write a check payable to Cerritos Republican Club for your choice of membership level. Mail the application and check to Cerritos Republican Club, P.O. Box 4193, Cerritos, CA 90703.

SIGNATURE _____________________________________________________________
I AM A (WE ARE) REGISTERED REPUBLICAN(S).

For Memberships of $100 or more, the below are required by the Fair Political Practices Commission.

Employer:
Business/Occupation:
Address: