Libertarian Party of Queens County - Membership Application

	Libertarian Party of Queens County Membership Form

(Please print this page, fill out form and mail back with your check)

Name ___________________________________________________

Address __________________________________________________

City ____________________ State ____ Zip __________

Home Phone __________________ Work Phone __________________

E-mail address ______________________________________________

Employer(*) ________________________

Occupation(*) _______________________

The Libertarian Party is guided by principle.
To publicly affirm what we believe - and to ensure that our party never strays from out principles - we ask our members to proudly sign this statement:

I do not believe in or advocate the initiation of force as a means of achieving political or social goals.

_____________________________________________________
(Signature required for membership)

PLEASE CHECK ONE OF THE OPTIONS BELOW

___ I do not wish to join now, but please send me more information.
___ Benefactor ($500)    ___ Patron ($250)    ___ Sponsor ($100)
___ Contributing ($50)    ___ Regular (**) ($20)

  Total Payment enclosed _______

Please make check or money order payable to:

The Libertarian Party of Queens County
c/o Procida Reality Corp.
161-09 29th Avenue
Flushing, New York 11358

* Federal law requires political committees to report the name, mailing address, occupation and name of employer for each
individual whose contributions exceed $200 in a calendar year.

** Please note: Only LPQC members who live in Queens County may vote on LPQC business matters.

Political contributions are not tax deductible

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URL: http://www.lpqc.org/membership.shtml
Last Modified: Sunday January 04 2004.
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