NAME______________________________________________
ADDRESS__________________________________________________________
CITY _______________________________________________________________
STATE___________________________ ZIP______________________
PHONE______________________________ DATE_______________________
E-MAIL ____________________________________________
MEMBERSHIP LEVELS
___ ANNUAL STUDENT $ 15
___ ANNUAL INDIVIDUAL $ 35
____ ANNUAL FAMILY $ 50
___ ANNUAL SLIVER $ 75
____ ANNUAL GOLD $ 100
____ ANNUAL EAGLE $ ____
Please, Personal Checks Only To:
URL (PAC)
13254 Northline Rd.
Southgate, MI 48195
urlpac1@yahoo.com
Paid for by the United Republican League (PAC), 13254 Northline Rd., Southgate, MI 48195