Florida Women's Political Network
affiliated with the
National Republican Women's Network

Application for Membership-At-Large 2012 

Print this form, and mail to address below:

Name __________________________________________________________________

Mailing Address _________________________________________________________

City, State, Zip __________________________________________________________

Home Phone _______________________ Fax Number ________________________

Place of Employment _____________________________________________________

Office Number ________________________  Fax Number _______________________

E-Mail Address __________________________________________________________

Party Affiliation:    _____ Republican    ____ Independent
      (Your Party Affiliation will be verified)

      By signing this application, I certify that I would like to become a member of the Florida Women’s Political Network.

Signature: ______________________________________________________________

  Please list organizations to which you belong and offices you hold or committees you chair and any other previous offices or committees on which you have served.

  (1)_____________________________________________________________________

  (2)_____________________________________________________________________

  (3)_____________________________________________________________________ 

Membership Dues:  $50.00 per year
Please send completed form and dues to: Pat Cogswell, 5902 Golden Road, Sebring, FL 33875-6099
Any questions, please call:  President Dolores Clark (352) 378-5247.