Complete and return with check or money order to:
Libertarian Party of Brevard County
1280 Sarno Rd PMB # 115
Melbourne, FL 32935-5204
Telephone Day __________________________ Telephone Night
Telephone Fax __________________________ Employer/Occupation
Email Address ____________________________ Date of Birth
__ I am a registered Libertarian (optional)
__ I am a member of the National Libertarian Party (optional)
Yearly Dues Schedule
$24 per year, prorated at $2 per month to complete the
May to May membership cycle.
Enclosed is $ ________ in dues to pay for my LPB membership until
mid-May of the year ________.
In addition, I want to help support the LPB with a contribution of $
"I hereby certify that I do not believe in or advocate the initiation
of force as a means of achieving political or social goals."
Signature _____________________________________ (required for membership
in the LPB)
Government Mandated Notices
The Internal Revenue Service requires us to print "contributions are not
tax-deductible" on all fund-raising appeals. Federal Election Commission requires us
to ask for your employer and occupation. Federal law requires political committees to
report the name, mailing address, occupation, and name of employer for each individual
whose contributions aggregate in excess of $200 in a calendar year.
Best Times To Be Contacted _______________________________________________________________
Best Times To Volunteer __________________________________________________________________
Best Day and Time for Monthly