Lakewood Ranch Republican Club Membership Application

Thank you for your interest in becoming a member of the Lakewood Ranch Republican Club. Please complete the application below in its entirety and submit your payment. Upon receipt we will confirm party affiliation of all new member applicants and send you a confirmation.
Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Email
example@example.com
Please note that this person will be considered the owner of a Couple/Family Membership.
Couple/Family Membership Owner?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your current cellphone number
Please enter a valid phone number.Format: (000) 000-0000.
Now enter your Home Phone number.
Please enter a valid phone number.Format: (000) 000-0000.
Please enter your Date of Birth.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you a current Member?
Are you a registered Republican?
Please indicate the type of Membership for which you are applying.
How many Family Members do you wish to add to your Couple/Family membership?
Please enter the Name of Family Member 1.

First NameLast Name
Please enter the Email of Family Member 1.
example@example.com
Please enter the Date of Birth for Family Member 1.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please enter the Name of Family Member 2.

First NameLast Name
Please enter the Email of Family Member 2.
example@example.com
Please enter the Date of Birth for Family Member 2.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please enter the Name of Family Member 3

First NameLast Name
Please enter the Email of Family Member 3
example@example.com
Please enter the Date of Birth for Family Member 3.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please enter the Name of Family Member 4

First NameLast Name
Please enter the Email of Family Member 4
example@example.com
Please enter the Date of Birth for Family Member 4.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Membership Owner
Has anyone referred you to the Club?
Please enter the name of the person who referred you.

First NameLast Name
Send payment made out to LWRRC to:
Marnie Matarese
7129 Westmoreland Drive
Sarasota, Florida 34243
Please note: As a Chartered Club authorized by the Republican Party of Florida, members are required to be a registered Republican subject to verification.
Should be Empty: