Membership Form

2017-2018
WELCOME TO DALLAS COUNTY TEJANO DEMOCRATS! YOU ARE IMPORTANT TO DEMOCRACY!
WE ARE VERY HAPPY TO MAKE YOU PART OF OUR VOTER FAMILY.
YOU COUNT YOUR VOTE SCREAMS!
Please complete the following information, especially your name, as it is on your Voter Registration Certificate. The Voter Registration
I.D. must be correct so as to match with the voter database: Please ensure you have provided the information from your voter
certificate. Please Print Legibly.

Membership Status: New Renewal At-Large

Name: Todays Date:
/ / 20_____

Home Address: City/State/Zip Code:

Mailing Address: City/State/Zip Code:

Ph Cell: Ph Hm: Ph Wk:

( ) - ( ) - ( ) -

E-mail: *Required if you do not have or know your Voter

Registration Number.
Date of Birth: / /

State Senate District: _________ County: Voter Registration #:

Precinct #: ______

$10.00 State Regular Membership Dues (Aug. 1, 2017 July 31, 2018) $10.00
$20.00 Local Chapter Membership Dues (Aug. 1, 2017 July 31, 2018) $20.00

Total Membership Dues : $30.00

*TEC Required *TEC Required

Occupation: Employer:

Signature:
(mandatory)

*Note: A convenience fee is applied for credit cards payments from our credit card company. Mail the completed
application and check to our address:
Dallas County Tejano Democrats
P.O. Box 225905
Dallas, Texas 75222

FOR OFFICE USE ONLY:

Amount Paid: $_______.____ Check, Cash, or CC: Check #: _____________ Amex / Visa / M-C / Discover Last 4 Digits: _____________
CC Swiped or Keyed? Square Receipt #: __________________ Square Authorization code#: ______________ Book Receipt #: _________________
QB Membership Invoice #: ___________ or QB Membership Sales Receipt #: _______________ Bank Deposit Date: ______/______/20____
Received by: ___________________________________ Note(s):