I Want to Join the  Georgia Green Party

I wish to make application for membership with the Georgia Green Party.  I am in basic agreement with the Ten Key Values and political practices of the Greens as a framework for organizing and political action.  I understand that payment of dues is not necessary to credential or participate at state conventions. 

___  Enclosed are my dues of $25.00/year. 
___  My means are modest.  I'm setting my dues at $15.00/year. 
___  I am unemployed. I'm setting my dues at $5.00/year. 
___  I'm accepting Ralph's challenge to give at least $100 and 100 hours a year to build this Party.  I authorize that the following visa / mastercard / amex account # __________________________ be debited for a total of: $_____________, as  ___ my monthly / quarterly / annual pledge of support to the ongoing development of the Georgia Green Party. 

Signature:  ______________________________________________
Name:  _________________________________________________
Address:  _______________________________________________
City, State and Zip:  _______________________________________
Email and website:  _______________________________________
Phone numbers:  __________________________________________
County:  ________________________________________________
Occupation/ Employer:  ____________________________________ 

___  Subscribe me to paper edition of the Internal Discussion Bulletin.  Enclosed is another $35.00. 
___  Yes, tell me about organizing a local. 
___  I want to host a Green Party event in my house or community. 
___  I'll circulate a ballot access petition. 
___ I’ll carry a clipboard and collect ___ 10, ___ 100, ___ 1000 ballot access petition signatures by the August 5th deadline. 
___  I'll distribute literature in my community. 
___  I pledge  ___ volunteer hrs. / week in preparation for the 2002 Election. 
___  I'm enclosing an additional contribution of: $_________________.