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GOLD PARTY

MEMBERSHIP APPLICATION FORM

(Print copy from this web site and fill in the blanks.)

Essential Information

NAME ______________________ ______________________ ___________________ _______
                                 last name                                              first name                         middle name                 suffix

ADDRESS __________________________ _________________ ______ _______ __________
                            street name and number                    city or town                  state    zip code     country

CONTACT _______________________ ________________________ ______________________
                                 main telephone number               other telephone or fax               email address

VOTE ASSIGNMENT TO OTHER MEMBERS ______________________ _____________________
                                                                                                                       recruiting member               other member

(Note: Members who join by Internet can assign the extra point to themselves.)

ANNUAL DUES PAYMENT   _____   _____   _____   ______   _______   ______   ______   ______
Check whichever applies:                $1         $15          $50         $100         $200         $500       $1000      $5000

ARE YOU A NEW MEMBER? _____ ______   ARE YOU REGISTERED TO VOTE? ______ _______
Check whichever applies:                 yes         no                                                                                                   yes               no

ARE YOU A U.S. VETERAN WHO SERVED IN WAR? ____________     ____________     ______________
Check whichever apply:                                                                            yes, a veteran         saw combat     wounded in service

Statement:         I join Gold Party of my own free will, not excluding membership in any other political party or obligating me to vote in any particular way in elections.

SIGNATURE OF APPLICANT _______________________________     DATE JOINED ______________

Optional information

AGE _________ GENDER __________               OCCUPATION ________________________________

DO YOU BELONG TO ANOTHER POLITICAL PARTY? _______ ________ ____________________
                                                                                                                                            yes               no                 If yes, which one?

WHAT POLITICAL ISSUES INTEREST YOU? __________________________________________

DO YOU WISH TO TAKE AN ACTIVE PART IN GOLD PARTY FUNCTIONS? ______ ______ _______
                                                                                                                                                                                             yes         no         maybe

OTHER COMMENTS OR QUESTIONS ________________________________________________________________________________________________________________________________________

Thank you. Your application is complete. Along with at least $1.00 in membership dues, mail paper copy to: Gold Party, P.O. Box 3944, Minneapolis, MN 55403 U.S.A. You will receive by return mail a confirmation of your membership in Gold Party along with a membership card.

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