Florida Fair Elections Coalition
Membership Application Form

O  New

O  Renewal
Name    
Address    
City, State, Zip  

_____________________________________
City

____
State

________
Zip
Telephone  

(            ) ________ - ___________________
   Area Code
Email Address  
Please Select Appropriate Membership Level
Student,
Senior (65+), Disabled		 O $15
Basic    O Single $20
O Family $35
Classic   O Sponsor $50
O Patron $100
O Benefactor $250
V.I.P.   O Silver $500
O Gold $1000
O Platinum (Any amount greater than $1000)

Enclosed is my check number

________

in the amount


$____________________
 

Mail form to Florida Fair Elections Coalition, 112 West New York Avenue, DeLand, FL 32720

FFEC is a non-partisan, non-profit organization, registered with the State of Florida Department of Agriculture and Consumer Services.
Registration Numbers: CH19386 and CH19387
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