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                          THE LEELANAU COUNTY DEMOCRATIC PARTY
                               2011 MEMBERSHIP FORM

  Name(s)__________________________________________________

  Address (If applicable, include both street address and P.O. Box)

          _____________________________________________________

          _____________________________________________________

          City_____________________________ State_____Zip________

          Telephone__________Email_____________________________
                (LCDP does not release email addresses of its members)

* Occupation_________________Employer Name_________________

* Employer Address__________________________________________
                                    (*required by law)

  Dues ($10/person/calendaryear)____________Donation___________
          (Dues and donations are not U.S. tax deductible)

  Please make checks payable to: Leelanau County Democratic Party
          and mail to: Leelanau County Democratic Party
                               c/o Charles Godbout, Treasurer
                               P.O. Box 215, Empire, MI 49630

                       Check here if you wish to be added to our list
                       of volunteers