PUTNAM COUNTY REPUBLICAN
EXECUTIVE COMMITTEE APPLICATION
Mail to:
Republican Executive Committee
Post Office Box 1885,
Palatka, Florida 32178-1885
Type Membership
Committee Person______ Precinct Number______ Alternate______
NAME_______________________________________HOME PHONE________________
STREET ADDRESS_______________________________________________________
CITY_______________________________________ZIP CODE__________________
MAILING ADDRESS______________________________________________________
CITY_______________________________________ZIP CODE__________________
EMAIL ADDRESS______________________________CELL PHONE #______________
PRESENT EMPLOYMENT_________________________BUSINESS PHONE____________
OCCUPATION, WORK EXPERIENCE__________________________________________
_____________________________________________________________________
_____________________________________________________________________
EDUCATION____________________________________________________________
BIRTH DATE:______________BIRTHPLACE:________________SEX:_____________
HOW MANY YEARS IN PUTNAM COUNTY?_______HOW LONG REPUBLICAN?__________
SPOUSE'S NAME________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY?____________________________
MILITARY SERVICE_____________________TYPE OF DISCHARGE_______________
POLITICAL OR PRECINCT EXPERIENCE_____________________________________
ACTIVE IN ORGANIZATIONS(Professional, civic, fraternal, etc.)________
_____________________________________________________________________
_____________________________________________________________________
Interested in participation in one of the following subcommittees,
Preferance 1 & 2:
Fundraising ( ) Research ( ) Finance ( )
Speakers Bureau ( ) Campaign & Candidate ( ) Telephone Comm. ( )
Headquarters Volunteer ( ) Typist ( )
Recommended by:____________________________PHONE_____________________
I accept the responsibility of organizing my precinct door to door,
including registration canvassing, vote canvassing and getting out
the vote on election day. I expect to help raise money for _________
_______________________________. I understand that my attendance at
monthly meeting on_______________________________is required.
Signed____________________________________Date_______________________
Why are you interested in politics here in Putnam County?____________
_____________________________________________________________________
Please return to Membership Chairman as soon as possible.
Date_____________Moved___________Resigned____________Dropped_________