Wufoo

LaCrosse County Democratic Party

Please fill out this form to become a member of the Democratic Party. A party official will be contacting you shortly to collect dues accordingly. Please make all checks payable to the LaCrosse County Democratic Party.

Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone - (###) - ### ####
Email
Which Assembly District do you live in?
95th Jennifer Shilling 94th Candidate Cheryl Hancock I'm not sure
Pledge your amount for dues
General ($25) Senior Citizen ($10) Pairs (includes two memberships) $35 Activist (up to 3 memberships) $45 Family Membership $75 Supporter $120 Friend $240 Patron $600 Investor $1200 Benefactor $2400
I would also like to pledge $ . Dollars Cents
I also recommend contacting as a possible member First Last
Phone - (###) - ### ####
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