Membership Application Form
The Maryland Public Assembly is organized to create a plaform of issues having broad consensus agreement in Maryland, and to endorse candidates for public office in the state who best reflect the public interest as determined by the Assembly membership. The Assembly is grassroots and non-partisan in nature, and open to all Maryland citizens of voting age. To join, complete and return this form with membership dues as indicated.
Name:_________________________ Tel.: _______________ Fax/email:_______________
Street____________________________________________ City__________________
State_______ Zip___________ Voting Precinct_________________
___Membership Dues ($20/yr)*
*Dues are waived in part or total for reason of poverty; if a written explanation of such poverty is provided (see below)
I wish to offer volunteer help: ___ clerical ___ telephone work ___ other (specify below)
I am interested in serving on the following Assembly committees:
___ Platform ___ Endorsement ___ Finance ___ Credentials ___ Public Information
___ Membership ___ Other (specify below)
Issues/Comments/Suggestions (use space on back or separate sheet if necessary):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Signature_________________________ Date__________
Amount enclosed: __________________(Checks payable to MPA)
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Other interested person(s) (list anyone you would like to receive information about the Assembly):
Name: _______________________ Organization: ____________________________ Telephone:_________________
Street:________________________________________________________ City:_____________________________
State: ______________ Zip: ______________
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Return this form to:
Lee Havis , Chairperson
Maryland Public Assembly
9525 Georgia Ave #200
Silver Spring , MD 20910
Tel. (301) 589-0733
email:havis@erols.com