Membership Form

LWVGB MEMBERSHIP FORM

First Name *

Middle Name

Last Name *

Email Address *

Please provide a valid email address if possible. If you do not have one, enter none@none.com

Address 1 *

Address 2

City *

State *

Zip *

Cell Phone

Prefered

Home Phone

Work Phone

What are your issue interests?

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Newsletter Delivery Preference

by email
do not send

Preferred Membership Type

Individual - Our regular "one person membership" - $55 per year
Family - For two people living in the same household - $80 per year
Student - For students enrolled in high school, college, university, or trade school - $15.00 per year.

Choose the membership type that you prefer.

ADDITIONAL HOUSEHOLD MEMBER

Is another member of your household (16 years of age or older) also joining? If so, please provide that person's name and email address here. Other information such as cell phone number and issue interests would be helpful.

Message

Questions? Other information you'd like to share?

I am at least 16 years old. *

What is 3+4? *

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LWVGB MEMBERSHIP FORM

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