The Dolphin Democrats - Chartered by the Florida GLBT Democratic Caucus

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Membership Application

Please indicate if this application is a:
New Membership OR Membership Renewal

Member 1 - Please select a membership type:
Voting Member Associate Member (non-voting)

Name
Address
City/State/Zip
Email Address
Home Phone
Cell Phone
Work Phone
County of Voter Registration
VOTER ID # / Precinct
Are you a DEC Member?	click if YES

Member 2 - Please select a membership type:
Voting Member Associate Member (non-voting)

Name
Address
City/State/Zip
Email Address
Home Phone
Cell Phone
Work Phone
County of Voter Registration
VOTER ID # / Precinct
Are you a DEC Member?	click if YES

Please Select a Membership Level:

SINGLE	HOUSEHOLD
Standard - $30.00	Standard - $50.00
Senior (62+) - $25.00	Senior (62+) - $40.00
Student - $25.00	Student - $40.00
Booster - $50.00	Booster - $100.00
Sponsor - $100.00	Sponsor - $200.00
Benefactor - $250.00	Benefactor - $500.00

Method of Payment:

On-Line
Mail a check

PLEASE COMPLETE YOUR APPLICATION BY CLICKING THE SUBMIT BUTTON BELOW.