Florida GLBT Democratic Caucus

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Member 1

Is This A Renewal ?

Yes

First Name
Last Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Email
County of Registration
Caucus Chapter (if member)
Voter ID
Precinct

Are you a DEC member?

Yes

Are you a member of the National Stonewall Democrats?

Yes

Committee Interest:
Meetings & Hospitality
Club Governance
Membership
Legislation
Campaign/GOTV
Recruitment & Outreach
Information Management & Technology
Fundraising

Membership Type:

Voting

Associate

Single Payment Level (select if 1 member applying only):

Standard ($25)

Booster ($60)

Sponsor ($125)

Benefactor ($525)

Member 2 (leave blank unless "Household")

Is This A Renewal ?

Yes

First Name
Last Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Email
County of Registration
Caucus Chapter (if member)
Voter ID
Precinct

Are you a DEC member?

Yes

Are you a member of the National Stonewall Democrats?

Yes

Committee Interest:
Meetings & Hospitality
Club Governance
Membership
Legislation
Campaign/GOTV
Recruitment & Outreach
Information Management & Technology
Fundraising

Membership Type:

Voting

Associate

Household Payment Level (select if 2 members applying only - do not select Single Payment Level in left column):

Standard ($40)

Booster ($110)

Sponsor ($240)

Benefactor ($1040)

Please note: If you would like to pay your membership by check, please PRINT THIS PAGE BEFORE CLICKING ON THE SUBMIT button and send the copy with your check to:
Florida GLBT Democratic Caucus, PO BOX 7492, Fort Lauderdale FL 33338. Please check this box if you will be mailing your payment.