Membership Form

Your Contact Information

Your Name*

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Membership Dues & Other Purchases

Please let us know what you paid.

New or RenewalNew MemberRenewal

Year Paid For

Date of Payment

Original Date Joined

Paid for MembershipGeneral $50 (women only)Associate Member $40Student Membership $25

Also Paid ForSponsor Newsletter $25Sponsor Directory $25Name Tag $12Luncheon Sponsor (Standard) $125Luncheon Sponsor (Premium) $225

Babe Atkins Byrne Scholarship Fund

Total Paid

Method of Payment OnlineCheck Check # (if applicable)

What are your areas of interest?

Select all of the areas of interest in which you want to be involved.

Campaign ActivitiesCampaignPhone BankElection DayConvention DelegateStaff GOP HeadquartersCandidate Forums

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MembershipRecruitmentHospitality

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Other Talents & ExperienceOther Talents & Experience

Permission

YESNO I give CCRWC permission to use my name and contact information in the CCRWC Member Directory, digital and printed versions. This information is for CCRWC member use and will not be shared by CCRWC with non-members.

YESNO I give CCRWC permission to use my name and/or image in CCRWC publications, hard copy and digital, including but not limited to the CCRWC newsletter and website.