Today's Date:
_______________________________________________
First Name: ____________________________________
Middle Name: _______________________________
Last Name: __________________________________
Street address:
______________________________________________________________________________________________________________
City: _____________________________________State: _______ Zip code:
_____________ - ____________
County:________________________________
E-mail: _______________________________________________________________
Contact phone number: _______ - _______ - ___________ Type: Home Office
Cellular
If needed, extension #______________________
Date of Birth: (month) __________ (day) __________ (year)
_______________
Do you belong to any other political groups? _________
If "Yes" than please list them and their websites (if known):
____________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Are you a union member? ________ If "Yes" than please name:
___________________________________________
___________________________________________________________________________________________________________________________________
Are there any special concerns that you'ld like to focus on or which
brought you to the SDUSA:
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Self-Assessed Annual Dues ($60 min.): $__________ Payment Schedule: annual[__], semiannual[__], monthly[__]
"Desiring to bring about, by democratic means, a social
democratic/democratic socialist society in which all exploitation has
been eliminated, I hereby apply for membership in the Social Democrats,
USA. I agree to abide by its principles and
platforms. I am not a member of a "democratic centralist" party or tendency."
Signature: ___________________________________________________________
Print this off and send it to:
Social Democrats, USA
P.O. Box 5307
Johnstown, PA 15904
Questions? Call Executive
Director Gabriel McCloskey-Ross at (814) 410-2542.
Office hours are variable, Monday-Friday, 1:30-5:30 pm EST and Saturday
12-3 pm EST, never on Sunday.