REVIVE OUR AMERICAN REPUBLIC

                                                  Membership Application

Red Level

Individual $25.00 Household $45.00 Veterans $5.00 Students or Seniors $15.00

White Level -$100.00 Household

Blue Level - $250.00 Household

Patriot Level - $500 Lifetime

Name Address City State Zip Code Phone E-mail Address Membership Levels: RED LEVEL:   (Annual Membership)                   ___Veterans ($5)  ___Individual ($25)____ Household ($45)___Student or Senior ($15)                                                                                           WHITE LEVEL:  (Annual Membership) ______$100 - Household membership receives a bumper sticker BLUE LEVEL:  (Annual Membership) ______$250 - Household membership receives a bumper sticker and a pen PATRIOT LEVEL:   (Lifetime Membership) ______ $500 - Household membership receives a bumper sticker, pen and certificate Annual memberships renewable April 15th. Optional Information: ______Male           ______Female   ______Number of voting household members   Age: ______18-25 ______26-35 ______36-49 ______50-65 ______over 65    I am enclosing a donation of: ______$200   ______$100   ______$50  ______$25  ______Other DONATIONS ARE NOT TAX DEDUCTIBLE This form may be emailed by clicking on the "submit" button. Please make checks payable to ROAR AMERICA and mail to: P.O. Box 19190; Golden, CO 80402 May we publish your name as a member of ROAR AMERICA    _____Yes _____ No

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