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1. Personal Information:    (Fields marked with * are required.)
Title *   
First Name *    Initial    Last Name *    Suffix
Address Line 1 *
Address Line 2  
City *     State *
Zip Code * -           County *

   Home Phone * ( ) -    Work Phone ( ) -    Ext
     Cell Phone   ( ) -                    Fax ( ) -  
E-mail   *
re-type E-mail   *
     
   Date of Birth *  / /      Registered * Repub    Dem    Other/Not
US Citizen: * Yes    No             Please send Membership Card: Yes    No

2. I would be willing to help with: (check all that apply)
Literature Drops    Door to Door    Phone Bank      Voter Registration
Poll Worker             Gun Shows       Attend Rallies   Letters to Editor/Writing


3. My representatives are:
     State Representative
     State Senator
     US Congressman


4. Join FOAC Now:
     Annual dues are $10.00.
     You may print this form and mail with your check to:
               FOAC
               P.O. Box 14
               Presto  PA  15142

          - OR (easier for both of us) -

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