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(Please print this form, fill out, and send with check to address at the bottom)

Northern Orange Republican Women (NORW)


2010 Membership Application

ANNUAL DUES: $35 (Payable to Northern Orange Republican Women) 

Additional Donation:______  Associate Dues: $25

The information below is needed for NORW use and to comply with federal regulations on political organizations

NEW MEMBER:  If you are a new member, previous member, or new associate member:

Name__________________________ Precinct_____________________

Spouse's Name___________________________________

Occupation___________________  Employer_____________________

Address______________________  City______________  Zip_________

Home Phone_____________  Work______________  Fax_____________

Cell_________________  Email__________________________________

Referred by:_____________________________________________

By signing below, I certify that I am a registered Republican and that I am applying for membership
in the Northern Orange Republican Women group.

Signature______________________________  Date________________


EXISTING MEMBER: If you are a member and are renewing your membership:

Name___________________________  Occupation_________________

Employer___________________  Spouse's Name__________________

Please provide your correct/newest information, especially any additions/changes to:

Address__________________  City________________  Zip__________

Precinct__________  Home Phone_______ Work_________ Fax_______

Cell____________  Email_________________________________________



Please check one or more of the following committees that interest you:

______Budget                 ______Membeship ______Ways & Means
______Bylaws                  ______Newsletter ______Fisher House
______Caring for America  ______Publicity        ______USO
______Hospitality ______Sunshine  
______Legislative ______Telephone

Please check one or more of the areas that interest you:

______Assist with events, get out the vote efforts or other volunteer activities
______Serve as a club officer

Print this form and mail with check to:  Jan Wassel, Treasurer,
5204 Rileys Ridge Road, Hillsborough, NC  27278