Jersey City Tea Party Alliance Membership Form

Date___/___/_____

For New Members (please print)

Name- First____________________ Middle____________________ Last ____________________

Street Address_________________ City____________________ State____ Zip Code__________

Home Phone___________________ Cell Phone___________________ Work Phone___________________

E-Mail________________________________________ Date of Birth___/___/_____

Occupation____________________________________

Employer____________________________________

Shirt Size______

New Membership Dues- $20.00

For Returning Members (please print)

Name - First ____________________ Middle____________________ Last____________________

Membership Number___________-____________

You don’t need to fill out the information below unless it has changed.

Street Address____________________ City____________________ State____ Zip Code__________

Home Phone___________________ Cell Phone___________________ Work Phone___________________

E-Mail________________________________________

Occupation____________________________________

Employer____________________________________

Returning Membership Dues- $15.00

Send this completed form

with a check or money order for the dues owed, payable to JCTPA Inc., to:

Anthony Di Iorio

1129 Avenue C

Bayonne, NJ

07002

Thank you for being an ALLY