Complete and return with check or money order to:
Libertarian Party of Brevard County
1280 Sarno Rd PMB # 115
Melbourne, FL 32935-5204
(321) 255-2105

Name __________________________________________________________________________________
Address ________________________________________________________________________________
City/State/Zip __________________________________________________________________________
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.

May	Jun	Jul	Aug	Sep	Oct	Nov	Dec	Jan	Feb	Mar	Apr
$24	$22	$20	$18	$16	$14	$12	$10	$8	$6	$4	$2

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.

Optional Survey

Hobbies ________________________________________________________________________________
Best Times To Be Contacted _______________________________________________________________
Best Times To Volunteer __________________________________________________________________
Best Day and Time for Monthly Meetings/Socials_______________________________________________

Regarding Public Speaking:

	__ I would like to participate in the calling tree
	__ I like to talk on the telephone
	__ I like to talk to people I have never met about Libertarianism
	__ I am a member of a Toastmasters Chapter
	__ I am willing to approach people door-to-door

I Would Be Willing To Share (or Learn) These Talents:

	__ Woodworking
	__ Organizational Skills
	__ Fundraising
	__ Typing
	__ Graphic Design
	__ Event Planning
	__ Campaign Experience
	__ Newsletter Experience (or Willing To Learn)
	__ Lettering
	__ Letter Writing
	__ General Writing
	__ Petitioning

I Would Be Willing To Provide (Within Reason) The Following:

	__ Legal Advice
	__ Database Skills
	__ General Computer Advice
	__ Storefront Window for Displaying Signs
	__ Access to Waiting Rooms for Displaying Literature
	__ Accounting Advice
	__ Printing Capabilities

__ Yes, you may include this information in a Libertarian Party of Brevard (LPB) Directory which will be available to members during the monthly socials

Suggestions and Comments

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This page was last updated 07/02/00 01:51 PM