Ashtabula County Republican Women’s Club (ACRW)    Application for Membership And Membership Renewal

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

               (House number and Street)

            _______________________________________________________________________________

               (City, State, and Zip Code)

_________________________________________________

               (If you receive your mail at a Post Office Box,

     Please enter the Post Office Box number on the line above.)

E-Mail Address:  ___________________________________________

Telephone Number – Landline: ________________________________

                                                            (Please include area code)

                                    Cell phone: ______________________________

                                                            (Please include area code)

Annual Dues:  Please make your check payable to ACRW

            $15.00 to $24.99 – MEMBER

            $25.00 to $49.99 – PATRON

            $50.00 and up – GOLDEN ELEPHANT

I am attaching cash.  The amount is: ____________________.  Thank You

I am paying by check.  The amount is:  __________________.  Thank You

Address for Mailing your membership or renewal: Ann Hegfield

                                                                                    210 Woodside Avenue

                                                                                    Jefferson, Ohio 44047