NAME:     _________________________________________________________/________________________

                                    LAST NAME, FIRST NAME                                                                                                                         SPOUSE

  ADDRESS: _____________________________________CITY: _________________________ ZIP___________

             PHONE: 903 - _________________ CELL: __________________E-MAIL: __________________________

SCHOOL DISTRICT: __________________________ PRECINCT #: __________(as listed on your voter registration card)
Donation to LCRP* of  $12 per year/per person = voting status in ALCR   
DONATION: $_______(MAKE ALL CHECKS PAYABLE TO *Lamar County Republican  Party)