THE
DEMOCRATIC PARTY OF VIRGINIA
Membership application form for the Gloucester County Democratic Committee
I the undersigned, hereby state that I am a Democrat, that I am a registered
voter in the precinct/county (as applicable) listed below, that I believe in
the principles of the Democratic Party, and that I do not intend to support any
candidate who is opposed to a Democratic nominee in the next ensuing election.
PLEASE PRINT:
NAME ___________________________________________________
CITY
/ STATE _____________________________________________
ZIP
____________________________________________________
PHONE (H)
_______________________________________________
(0) _______________________________________________
EMAIL ADDRESS __________________________________________
PRECINCT /
SIGNATURE
_______________________________________________
DATE
____________________________________________________
Make check payable to GCDC (membership dues $20.00)
Please mail Application Form
and Check to:
Pat Cooney, Treasurer