North Dallas Chapter TEXAS DEMOCRATIC WOMEN

                                        www.nddw.org         info@nddw.org

                        Membership Application & Renewal Form

NAME_____________________________________E-MAIL__________________________________

ADDRESS_______________________________CITY____________COUNTY________ZIP_______

SPOUSE or PARTNER’S NAME_____________________BIRTHDAY: Month______Day________

EMPLOYER*______________________________OCCUPATION*____________________________

PHONE NUMBERS: Hm________________________________ Wk___________________________

Cell _______________________________ FAX__________________________

ELECTED/APPOINTED OFFICES _____________________________________________________

NOTIFY ME OF: Book Club Meetings ______ Movie Club Outings _______Bunco Parties______

  • CHAPTER: North Dallas PRECINCT # _________CONGRESSIONAL Dist.__________
  • SENATE Dist.___________ HOUSE Dist. ____________
    •

    *Required for reporting to Texas Ethics Commission

    (   ) New Member     (   ) Renewal  (   ) Update Information Treasurers’ use only:___________Date Dues Accepted

    MEMBERSHIP LEVELS**

    (check one)

    ____$ 40.00 Ann Richards Level

    ____$ 75.00 Rosa Parks Level

    ____$125.00 Eleanor Roosevelt Level

    ____$ 10.00 Student

    Payment Information:

    Checks: Payable to "NDTDW" or Charge my: Visa ____M/C ____Amex ____Disc____

    Name Shown on Card_______________________ Card Number______________________

    Expiration Date____________

    Mail payment and this completed membership form to:

    Lenna Webb, 17201 Hidden Glen Drive, Dallas, TX 75248

    NOTE: Dues renewals are due each year on the 1st of January. New members who join after September 1st are paid for that fiscal year and the next.

    VERIFICATION: By my signature below, I certify I am a Democrat who supports the increased political activity and influence of Democratic women in Texas politics and government, I am over 18 years of age, and I am not a foreign-born national. I understand that the North Dallas Chapter of Texas Democratic Women is a General Purpose Political Action Committee. (GPAC)

    Please check one: I agree to have my name printed as a member in the NDTDW newsletter. [    ]Yes [    ] No

    Signature ______________________________________________________Date______________________

     Money earned by TDW may be used for political purposes.