Name____________________________________
Address__________________________________
City/State/Zip_____________________________
Phone___________________________________
E-Mail___________________________________
Dues-
Individual- $15.00 _______
Family- $25.00 _______
Student- $5.00 _______
Gold*- $100.00 _______
Additional Contribution- _______
Scholarship Contribution- _______
Total Remitted- _______
*Gold membership includes family membership and two Lincoln Dinner tickets.
Make checks payable to: Presque Isle County Republican Party
Mail to: Barbara Durflinger, Treasurer
14946 Royston Road
Hillman, MI 49746