Mail Membership Application

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Annual Membership Application

Please complete the membership application and mail membership fee to:

2979 Middlecoff Lane, Florence, SC 29506.

Bill Pickle - Chairman (843-260-7806) or Elijah Jones - Secretary (843-992-7664)

Required *

Annual Membership Level *

Select Title * Mr. Mrs. Ms. Miss Family

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Family Member Names

Date of Birth *

E-mail Address

Home Number *

Work Number

Occupation

Employer

Precint/Voting Location

Communication Preference *

Committee Information (Hold the CTRL button to select more than one option.)

* Federal Law requires that you verify the following statements are true and accurate by checking the box below.

Yes *

I am a United States citizen or a permanent resident alien. This contribution is not made from the general treasury funds of a corporation, labor organization or national bank.

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