Virginia
Citizens Defense League, Inc. • P.O.
Box 513, Newington, VA 22122
• 804-639-0600
VCDL Membership
Application
| |
_______New
|
| |
_______Renewal
(Membership Number: _____________ ) |
| |
|
| Name: |
__________________________________________________ |
| Address: |
__________________________________________________ |
| City: |
__________________________
State: ____ Zip: __________ |
| Phone: |
( ______
) ___________________ |
| E Mail: |
__________________________________________________ |
| |
|
| |
Special
Skills / Comments
|
| |
___________________________________________________ |
| |
___________________________________________________ |
| |
___________________________________________________ |
| |
___________________________________________________ |
| 1 year VCDL
membership: |
$
25.00 |
| Donation
to VCDL: |
$ |
| Donation
to VCDL-PAC (Political Action Committee): |
$ |
|
Total:
|
$ |
| Method
of Payment |
| |
|
| _______ |
Cash (Please
do not send cash through the mail) |
| _______ |
Check (Make
payable to VCDL) |
| _______ |
Charge:
_____ American Express _____ MasterCard
_____ Visa |
| |
Credit
Card Number: _________________________________________ |
| |
Expiration
Date: _______________ |
| |
Name on
Card: _____________________________________________ |
| |
Date: ______________ |
| |
Signature
of Cardholder: ______________________________________ |
Contributions, gifts, or membership dues
are not deductible as charitable contributions for Federal income tax
purposes.