* REFORM PARTY OF MICHIGAN *

APPLICATION FOR MEMBERSHIP

NAME_________________________________________________________

ADDRESS______________________________________________________

CITY/STATE/ZIP____________________________________________________________________

PHONE_________________________________EMAIL_____________________________________

+ SINGLE ($20/year contribution) ..+ HUSBAND/WIFE ($30/year contribution)

* SENIOR/STUDENT ($10/year contribution)..* OTHER CONTRIBUTION $_________ * NO CONTRIBUTION 0

Please make checks payable to Reform Party of Michigan. Send to: Reform Party of Michigan, 914 Beechwood St. NE, Grand Rapids MI 49505. Thank your for your contribution and for joining the Reform Party. Someone will be in touch with you soon to let you know about activities in your area.

Although it is not required, your voluntary membership contribution is greatly needed and appreciated.

*** FOR AMERICA FIRST! ***


* REFORM PARTY OF MICHIGAN *

APPLICATION FOR MEMBERSHIP

NAME_________________________________________________________

ADDRESS______________________________________________________

CITY/STATE/ZIP____________________________________________________________________

PHONE_________________________________EMAIL_____________________________________

+ SINGLE ($20/year contribution) ..+ HUSBAND/WIFE ($30/year contribution)

* SENIOR/STUDENT ($10/year contribution)..* OTHER CONTRIBUTION $_________ * NO CONTRIBUTION 0

Please make checks payable to Reform Party of Michigan. Send to: Reform Party of Michigan, 914 Beechwood St. NE, Grand Rapids MI 49505. Thank your for your contribution and for joining the Reform Party. Someone will be in touch with you soon to let you know about activities in your area.

Although it is not required, your voluntary membership contribution is greatly needed and appreciated.

*** FOR AMERICA FIRST! ***