If you would like to become an active member of and/or suport the Concord Republican City Committee, please use the PRINT function on your browser to print out this page, fill out the required information, and mail (with check made payable to "Concord Republican City Commiteee"), to: Barbara Barrett, Treasurer, Concord Republican City Committee, P.O. Box 1533, Concord, NH 03302-1533.

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ANNUAL DUES PAYMENT(S) ENCLOSED:

[_]  2010 Membership Dues, $10
[_]  2011 Membership Dues, $10

ADDITIONAL VOLUNTARY CONTRIBUTION:

[_] $5,000*     [_] $1,000*     [_] $500*    [_] $250*     [_] $100     [_] $50     [_] $25
[_] Other amount: $ _____________

Total amount enclosed: $ _____________

UPDATED CONTACT INFORMATION:

Your Title (circle one): Mr. / Mrs. / Ms. / Dr. / Rev. / Hon.

First Name: ________________  M.I. _____ Last Name: _________________

Street or P.O. Box: _______________________________________________

City/State/ZIP: ___________________________________________________

Home Phone: ____________________ Work Phone: ____________________

E-Mail: _________________________________ Fax: ___________________

[_]  Please send me information by e-mail only

*If this contribution exceeds $100, or if this contribution, when combined with other contributions you have made for the 2010 New Hampshire State Primary Election cycle, (which runs through September 14, 2010), exceeds $100, please supply the following additional information, which we are required by New Hampshire RSA 664:6, I, to collect from our most generous donors:

Occupation: ___________________________ (if retired or homemaker, so state)

Name of your employer: _________________________ (if self-employed, so state or list the name of your corporation, LLC, partnership or other business entity)

City and state of your principal place of business: _____________________________

Please note that contributions to the Concord Republican City Committee are not tax-deductible for charitable purposes. 

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THANK YOU!!!!!!